' tIBRARY '^•
UNIVg!»i.TY OF
CALIFORNIA
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UNIVERSITY OF CALIFORNIA SAN DIEGO
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DERMOCHROMES
SIXTH REVISED EDITION
PORTFOLIO
OF
DERMOCHROMES
BY
JEROME KINGSBURY, M.D.
ATTENDINQ PHYSICIAN NEW YORK SKIN AND CANCEB HOSPITAL; PHYSICIAN FOB DISEASES
OF THE SKIN TO THE PKESBYTEBIAN HOSPITAL DISPEXSAHY; MEMBER OF THE
AMERICAN DEEMATOLOGICAL ASSOCIATION; ifEMBER OF THE NEW
YORK DERMATOLOOICAL SOCIETY, ETC.
CHAPTERS ON SYPHILIS
BY
WILLIAM GAYNOR STATES, M.D.
ASSISTANT STJBQEON NEW YORK POLYCLINIC HOSPITAL; FORMERLY INSTRUCTOR IN OENITO-
UBINABY AND VENEREAL DISEASES; MEMBER OF THE AMERICAN MEDICAL
ASSOCIATION; MEMBEB OF STATE AND COUNTY MEDICAL SOCIETY
OF NEW YORK, WEST SIDE CLINICAL SOCIETY, ETC.
WITH TWO HUNDRED AND SIXTT-SIX COLORED ILLUSTRATIONS
AND SIX HALF-TONE FIGURES
Volume II
NEW YORK
REBMAN COMPANY
herald square building
141-145 West 36th Stbeet
^{l Righti reterved
COPTBIOHT, 1921, BT
REBMAN COMPANY
New Yobk
PBINTED IN AMEBICA
Plate 57.
Fig. 89. Lingua scrotalis.
hig. 90. .Aphtiiae.
Lingua Scrotalis
Plate 57, Fig. 89
This affection, scrotal tongne, so-called from its resemblance to a
contracted scrotum, is also known as lingua plicata, and by Mikulicz
is called macroglossia with furrow formation. This affection is
purely congenital and has also a familial incidence. The entire
tongue is symmetrically enlarged, but is of normal contour. Its sur-
face, however, instead of being smooth, is thrown into folds, numer-
ous, and showing considerable bilateral symmetry. The median fold,
corresponding to the middle line, is the deepest, as a rule. The entire
tongue seems to be marked off into lobules. The papillae are not
enlarged and may be missing.
There are no especial symptoms beyond what has already been
stated. The condition roughly resembles the lobulation which fol-
lows sclerotic glossitis. The geographic tongue sometimes shows
lobulation.
Treatment
There are no indications whatever for treatment, at least none
which could be carried out.
Pig. 89. Model in Freiburg Clinic (Johnsen).
107
Aphthae
Plate 57, Fig. 90
Aphthfe or aphthous stomatitis is an affection described in 1823 by
Billard, characterized by multiple white circumscribed, superficial
fibrinous patches. Fibrin is deposited in the midst of the epithelial
cells with resulting death of the same.
The clinical picture is highly characteristic. In any locality in the
mouth, notably on the tongue and lips, there appears an eruption of
white or yellowish spots, these vary in size and are round or oval, and
sharp contoured. They run a brief course and the epithelium is then
exfoliated or shed, revealing a newly regenerated layer. The disease
is kept up by the continuous formation of new aphthae. The lesions
are extremely sensitive, so that eating and speech are difficult. As
the affection is largely peculiar to young infants — one to three years
of age — it is prone to be attended by fever. Salivation is naturally
present. "Women also suffer from it in connection with all of the
reproductive phenomena, and a stomatitis aphthosa not distinguish-
able in any way often complicates the acute infectious diseases of
childhood. Certain individuals seem to be predisposed to attacks of
aphthae.
Etiology
Aphthae of the mucosa appear to resemble closely vesicles OH the
skin, save that the exudate in the former is fibrinous. Impetigo has
been produced artificially from inoculation with aphthous material.
The staphylococcus aureus is often met with in the secretion of
aphthae. Children who are subject to aphthae either have diminished
general resistance, as in scrofula and rickets, or the mouth is in a
vulnerable condition from some pre-existing local disease.
Diagnosis
The possibility of foot-and-mouth disease must be kept in mind.
108
Prognosis and Treatment
Aphthae are so sure of spontaneous cure after a varying interval
that their clinical importance is inferior. The tendency to recurrence
of the lesions furnishes the real indication of treatment, but nothing
is required beyond the use of antiseptic mouth washes. Caustics do
not do good. General roborant measures are naturally indicated.
Fig. 90. Model in Polyclinic of Prof. M. Joseph in Berlin (Kolhow). i
109 '
Stomatitis Mercurialis
Plate 58, Fig. 91
This affection, due to general mercurial intoxication, bears so close
a resemblance to ordinary ulcerous stomatitis as at first sight to
suggest that there is no specificity involved. It begins about the teeth,
especially carious teeth and stumps and the -wisdom teeth. The in-
volved gums swell, and salivation is present. Next the portions of
the cheeks and tongue which come in contact with the affected teeth
participate. At the same time the process extends along the gums.
At the junction of the latter with the teeth a yellow, pultaeeous mass
forms, consisting of cast-off epithelia, tartar and bacteria. The
breath has now become extremely foul and exceedingly characteristic
of its mercurial origin. Ulceration now begins under the pultaeeous
deposit. The ulcers have a yellowish or greenish flow of lardaceous
quality and are surrounded by a broad, bright-red areola. Ulcers
also appear here and there upon the mucosa of the mouth and tongue.
The entire mucosa swells, the cheeks receive the impression of the
teeth, the tongue may attain such size that the mouth cannot be closed.
Even in the worst cases there may be portions of gum l^ft intact. In
the severe cases the patient naturally presents symptoms of general
hydrargyrism. In individuals "w^ith good teeth and mouth care the
only lesions may be a few scattered ulcers on the cheeks and tongue.
Eiiology
The mercury may be received into the system in any of the pos-
sible ways. Cases from the therapeutic use seldom occur to-day, for
a variety of reasons, and all measures are taken to prevent this acci-
dent. In the industrial arts there is also prophylaxis, but cases are
il occasionally reported in looking-glass makers, bronze workers, etc.
Diagnosis
The tenderness of the gums on striking the teeth together and the
peculiar breath odor should suffice for a correct diagnosis.
110
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Treatment
The most scrupulous asepsis of the month must be observed, with,
of course, cessation of exposure to mercury. The mouth should be
irrigated with solutions of boric acid, hydrogen peroxide, or chlorate
of potassium. In very severe cases, iodoform should be applied in
any efficacious manner between the gums and cheeks.
Fig. 91. Model in Finger's Clinic in Vienna (Hennmg).
Ill
Dyschromia Gingivae Saturnina
Plate 58, Fig. 92
This condition is the ''lead line" which forms on the gnms in sub-
jects affected with saturnism. Plumbers and other workers in lead
develop as one phase of poisoning with the same, stomatitis with
gingivitis and swelling of the mucosa almost wholly confined to the
margin of the gum. In this locality fine particles of metallic lead or
lead sulphide are deposited, the clinical result being the line in ques-
tion. This is bluish-gray or bluish-black in color. The patients are
often unaware of its existence. The breath has a peculiar character-
istic odor. The lead reaches the mouth through the salivary glands,
which may inflame. The lead line has great diagnostic significance.
Treatment
The management of lead poisoning in general is indicated,
together with antiseptic mouth washes.
Fig. 92. Model in v. Bergmann's Clinic in Berlin (Kolbow).
112
Plate 59.
Fig. 93. Miliaria rubra.
Miliaria Rubra
Synonyms: Lichen tropicus, Prickly heat
Plate 59, Fig. 93
This eruption consists of inflammatory miliary vesicles and pap-
ules at the mouth of the sweat-follicles. The small clear vesicles
representing occluded sweat-pores may become inflamed so that some-
times a complex state results. The affection occurs during intense
paroxysms of sweating, producing a characteristic prickly sensation
added to ordinary itching. The covered parts in which radiation is
most difficult, suffer chiefly. In some individuals prickly heat is
most apparent after cooler weather succeeds great heat. Profession-
ally it is seen in workers at high temperatures who drink beer or
even water to excess. Strophulus is a local miliaria occurring only in
infants on the surfaces which are naturally warmest.
Etiology
The trouble is caused by excessive heat and the wearing of heavy
underwear. It is most common in obese subjects, especially in those
overheated by injudicious eating or drinking.
Diagnosis
The recognition of this affection is seldom difficult, although at
times it may suggest acute vesicular eczema.
Treatment
Cooling diuretics and laxatives with a light diet afford the quickest
relief. Sedative lotions and dusting powders relieve the pruritus
and with the removal of the causal factors the eruption soon
disappears.
Fig. 93. Model in Neisser's Clinic in Breslau (Kroener).
113
Folliculitis Barbae
Synonym: Sycosis non-parasitica
Plate 60, Fig. 94
This affection is not to be confounded with ringworm of the beard,
which is sometimes termed parasitic sycosis. Since eczema, when it
attacks hairy localities, shows a tendency to suppurate from acci-
dental infection with pyogenic microorganisms, it might at first sight
be assumed that foUiculitus barbae is only an eczema of the bearded
area. This, however, is by no means the case, for a similar purulent
folliculitis may occur in any area covered with hair. The scalp is
rarely attacked, save at its borders. The eyebrows may be involved
and sometimes the pubes and axillae. It is not recorded that a
generalized folliculitis of all the hairy integument can occur in a
single subject. The opposite tendency is more in evidence and even
in a preferred locality, like the beard and mustache; the disease is
often limited to definite areas. In some instances, as in sycosis of
the middle of the upper lip, the predisposing or exciting cause is
connected with a discharge from the nostrils. In other cases the
affection seems to take root in a particular locality and travel from
follicle to follicle by local infection. The degree of suppuration, the
amount of scarring and obliteration of follicles, and the presence or
absence of keloidal scarring all combine to characterize individual
cases.
Etiology
Folliculitis barbse is regarded at present as due to the entrance of
ordinary pyogenic staphylococci into the follicles of the beard and
elsewhere. In certain cases pus does not form, so that only a papular
folliculitis occurs. The reaction to the disease varies greatly with
the individual. Infiltration about the follicle may be slight or exten-
sive. It was formerly taught that the hairs of the beard were not
loosened by the disease, but this sometimes occurs. Some patients
seem naturally disposed to loss of substance and scarring ; so much
so that a grour> disease of necrotic foUiculitides may in time be
established.
114
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Diagnosis
To distinguish between ringworm of tlie beard and sycosis is of
first importance and this is readily done by epilation and examining
the hairs for fungi.
It is very difficult to differentiate radically between eczema limited
to the beard, etc., and sycosis, the chief marks of distinction being
largely academic. Sycosis does not itch much, and a drop of pus may
be squeezed from a follicle.
Pustular acne may also be mistaken for sycosis, but in acne the
pustules are larger and there is generally other evidence of sebaceous
disease.
Some of the lesions of syphilis may at times resemble sycosis.
The pustular syphiloderm which might be mistaken for sycosis is
never confined to the face alone and the late papular tubercular
syphilide, which might be limited to one region, would seldom be
symmetrical, as in sycosis. The lesions would be larger, less acutely
inflammatory, and would not exhibit the pustular points surrounding
the hair-follicle.
Prognosis
As in folliculitis from other causes the disease is naturally very
chronic and refractory to treatment. It is very difficult to destroy
the organisms in the follicles.
Treatme7it
The beard must be clipped short, for the irritation caused by the
growing hair is great. Soothing applications are then indicated until
the patient is able to shave. This is practically as beneficial as epila-
tion, an old resource. The patient is now placed upon mild antiseptic
ointments, white precipitate or sulphur usually having the preference.
If the face is considerably irritated an ichthyol or diachylon ointment
may be substituted. In chronic cases good results are often obtained
by the use of X-rays. Autogenous vaccines are probably of more
value in folliculitis barbae than in any other cutaneous affection.
Fig. 94. Model in Freiburg Clinic (Johnsen),
115
Acne Varioliformis
Plate 60, Fig. 95
The resemblance of this affection to variola lies only in the scars,
for the lesions are of very slow evolution. The expression acne
varioliformis has also been applied for years to molluscum contagi-
osum; so that in some quarters the term folliculitis varioliformis is
used. The lesions, discrete papulo-pustules, occurring on the face,
naturally resemble an acne, but show a special tendency to occur on
the forehead, especially along its hairy border. They also extend well
into the hairy scalp and this fact alone serves to differentiate the
affection from ordinary acne. Another important point is the absence
of comedones and of anything like free suppuration. The pus in the
centre of the pustules cannot be squeezed out, and this is not due to
any perifollicular location, but only to the fact that the central core
is not really pus but a yellow slough. This forms and separates very
slowly and the loss of tissue is replaced by a depressed scar or pit.
Although the lesions are chiefly discrete they sometimes occur in small
groups. Some individual lesions may be as large as a bean, and if a
number of large lesions are closely aggregated there is at times a
marked resemblance to syphilis.
Etiology
The affection is rather rare and little is known as to its intimate
nature. Those who do not believe in the individuality of so many new
diseases incline to regard this affection as a tuberculide.
Diagnosis
The differential points of common acne have already been outlined
— location, character of pustule, etc. The Wassermann reaction
should help distinguish it from syphilis.
Prognosis
The disease is an obstinate one, and also tends to recur, but is
curable.
116
Treatment
Applications must be made to penetrate into the follicles with a
view of preventing new lesions. The integument should first be pre-
pared with a salicylic acid ointment, after which sulphur, ammoniated
mercury, naphthol, resorcin or other bactericide appears to be suflS-
cient, with patience, in removing the affection.
Fig. 95. Model in Neisser's Clinic in Breslau {Kroener).
117
Acne Vulgaris
Plate 61, Figs. 96 and 97
This affection, nominally almost peculiar to the sebaceous glands
of the face with a slight tendency to extend over the shoulders may
exceptionally occur thickly over the upper two-thirds of the back, in
which situation its relationship to these glands is much less apparent.
In certain individuals acne may also occur on the limbs, nor is there
any evidence that these subjects are notably in poor general condi-
tion or uncleanly. The incidence of the disease upon the face is
readily explained by the prominence of the sebaceous glands in this
locality, the patent state of the outlets and the tendency for these to
become obstructed from "within or ^\•ithout. Acne, however, is much
more than a mere obstructive affection, for in the worst lesions the
chief mischief occurs and may begin outside of the follicles. Dermic
abscesses often form on the face and back, some of these being quite
extensive, and deep pits result which sometimes resemble those of
smallpox. Nor in cases where these lesions occur is there any evi-
dence that the process necessarily began with obstruction of the se-
baceous outlets. Treatment directed to cleansing the skin and open-
ing the pores may not be able to avert the formation of these
perifollicular lesions. For these and other reasons an attempt was
long made to distinguish radically between acne vulgaris, the obstruc-
tive type of acne of the face and acne indurata, occurring on the face,
shoulders and back alike, and consisting essentially of perifollicular
suppuration. At the present time this distinction is only made from
the clinical standpoint, as it is impossible to state where one begins
and the other ceases.
Acne vulgaris in the narrow, clinical sense can often be traced
step by step. Beginning wath a plugging of a sebaceous duct, the
lesion is then kno-wn as a comedo or black head. The first evidence
of follicular reaction, as shown by the formation of a reddened papule,
is termed acne papulosa, or pimples. As a matter of fact, however,
the papules of acne very often represent pustules which have been
evacuated. When pus forms in the centre of a papule, as a result of
118
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infection within the latter, the condition constitutes an ordinary acne
pustule or pimple which has come to a head. Large papulo-pustules,
slow of evolution, which do not come to a head, and which often do
not discharge any pus, represent a deep-seated inflammatory process
which involves a group of sebaceous follicles. In certain cases pus
either does not form at all, or becomes encysted ; so that nodules may
persist in the skin for weeks, or until fresh suppuration occurs. In
some of the larger lesions several foci or pus may form, and these
may coalesce to produce a large cavity. In many cases the dermic
abscesses behave like the cold abscesses of scrofulous subjects and
occur in patients of a marked scrofulous habitus.
Acne is essentially a multiform affection in which comedones,
papules, small pustules and perifollicular abscesses may occur side by
side. Certain cases never pass much beyond the comedo stage, and
many have no other lesions than comedones and small papulo-pus-
tules. It by no means follows that the latter do not scar, for they
often produce fine pits; but these tend in time to become hardly
perceptible. A characteristic feature of acne lesions is that they are
disseminated quite uniformly. Although there appears to be no good
reason why many contiguous follicles do not become involved to-
gether, it is a fact that acne lesions do not coalesce to form large
patches. We have already seen that some coalescence of perifolli-
culitis is necessary to produce the large indurations and abscesses.
Acne tends to come out in successive crops or continuously, and there
is a considerable relation between the character and duration of the
lesions. Small papulo-pustules may go and come quickly, larger ones
have a much longer cycle. The indurated lesions which cannot be
evacuated may persist for weeks. Acne on the back seldom bears any
relationship to acne of the face. The latter may show but few lesions
in a patient whose back is densely covered.
Etiology
The tendency of an acne to begin about puberty and to disappear
spontaneously within a number of years, shows the presence of a
marked developmental element. Acne depends so closely on so many
different factors that these must be regarded as elements, which, how-
ever dissimilar, all tend to make the follicles a culture medium for
various pathogenic germs. The number of dietetic articles which may
determine acne in different individuals is very large. For each pa-
tient there are a few classes of food or single articles which cause the
breaking out, and it is not impossible that anaphylaxis is responsible.
119
Otherwise it is hard to understand how in some subjects, nuts, cheese,
etc., always appear to deternoine new lesions. The claim was once
made that a dilated stomach is largely responsible for acne lesions,
and that if this underlying condition is treated properly much benefit
results. Constipation is often clearly associated with the formation
of comedones and intestinal autointoxication due to constipation is
also a factor. Menstruation is often sufficient to produce a number of
papulo-pustules which run their course rapidly. The part played by
microorganisms is very evident, but the disease is not contagious and
it is doubtful if it is even autoinoculable.
Diagnosis
Acne vulgaris may be confused with iodic and bromic pustules.
The only actual disease which may simulate it is the papulopustular
syphUide, and this shows certain groupings and does not spare any
area, while acne does not occur in the eyebrows or on the eyelids.
Prognosis
Acne vulgaris is often very hard to control during the first years
of its existence, but after puberty is well over it responds better to
treatment.
Treatment
The treatment of acne is both general and local, and to be of per-
manent value should be continued faithfully for a long time.
General treatment consists of hygienic, dietetic and medicinal
measures calculated to improve the physical condition of the patient.
Cold bathing or sponging, as much out-door exercise as the pa-
tient's strength permits of, with regular hours for eating and sleep-
ing, should be insisted upon. Late hours, especially with late suppers,
are injurious, and all foods liable to cause gastrointestinal fermenta-
tion should be avoided. It is always advisable to impress the neces-
sity of this firmly upon the patient. Fried greasy food, rich soups
and gravies, and pickles and cheese should be eliminated from the
dietary.
For the gastric fermentation the following rhubarb and soda mix-
ture will be found serviceable :
5 Pulv. rhei 3i
Sodii bicarbonat 3iii
Aquae menth. pip 5"*
M. et ft. Sig. — Teaspoonful after meals.
120
If there is atony of the stomach-walls, 3ii of tincture of nux vomica
can be added to the above ; and if constipation is also present, 3ii to
3iv of the aromatic fluid extract of cascara sagrada can be added also,
or the cascara can be given in the form of tablets at bedtime.
In plethoric patients Bulkley recommends :
19 Potassii acetatis 3vi
Tinct. nuc. vomica 3ii
Ext. cascara sagrada fl 3ii
Ext. rumex fl ad Jiii
M. et ft. Sig. — Teaspoonful in water one-half hour before meals.
Anemia must be treated with iron and arsenic tonics. The elixir
of iron, quinia and strychnia is a valuable preparation, and the follow-
ing will be found exceptionally good:
^9 Ferri et ammoni. citratis 3i
Liq. potassi. arsenitis 3i to 3ii
Liq. potassias 3i to 3ii
Tinct. nuc. vomica 3ii
Tinct. gentian comp Ji
Aquae ad "^w
M. et ft. Sig. — Teaspoonful in water after meals.
Where constipation with anemia exists, the following modification
of Startin's mixture is excellent:
^ Ferri sulphatis 3i
Magnesii sulphatis 3iv to Ji
Acidi sulphurici diluti,
Syrupi zinziberis aa 3iv
Aquas ad Jiii
M. et ft. Sig. — Teaspoonful in glass of water after meals. Take
through a tube.
This is especially good in the indurated type with large
pustules.
The local treatment of acne is very important.
All comedones should be removed mechanically and the pustules
opened ; this hastens the cure and lessens the scarring. This should
always be done by the physician and never left to the patient.
The face should be washed in cold water only and no soap should
be used. Steaming the face and using hot water leaves the pores
dilated and increases the tendency to comedone formation.
The plan used so much abroad of using peeling ointments is seldom
121
advisable. It can be used occasionally on the forehead when large
numbers of blacklieads are present; but its use must always be
followed by the regular routine treatment described below.
The following ointment causes desquamation. It should be spread
thickly over the part to be peeled and allowed to remain in place for
about an hour, then removed with dry cotton. This is repeated daily
for three or four days.
^ Betanaphthol 9ii
Pulv. sulphur precip 3iv
Saponis mollis,
Paraffini mollis aa 9v
M. et ft. Sig. — Scaling paste (Lassar).
When dermatitis develops water must not be used, but a bland
dusting powder or a soothing lotion can be applied to relieve the feel-
ing of tension and burning. After desquamation has begun a mild
ointment such as cold cream or boric acid ointment can be used.
The best results are obtained by the use of lotio alba, to which
three per cent, of precipitated sulphur is added.
IJ Pulv. sulphur precip.,
Zinci sulphate,
Potassii sulphuret aa 3i
Aqua? rosas ad '^iv
M. et ft. lotio.
The potassium sulphuret should be fresh, as it changes on ex-
posure, and the lotion made from an old article is practically useless.
As the skin becomes tolerant, the strength of the lotion can be in-
creased three or four times. This is to be applied thickly night and
morning.
When the skin is very oUy and the pores become clogged easily, it
is advisable to apply the above at night and use the following in the
morning, rubbing in well:
^ Pulv. sulphur precip Si
Etheris sulphurici 5iv
Spr. vini rect ad §iv
M. et ft. lotio
Occasionally the patient's skin will not tolerate the above, espe-
cially in the beginning of the treatment. In these cases the following
modification of the Kummerfeldt lotion is useful:
122
^ Pulv. sulph. prep 9 ii i
Camphori gr. vi ]
Pulv. acaciae 9 i
Aquas calcis 3iv
Aquffi rosas ad ^iv
M. et ft. lotio
Seborrheic dermatitis of the scalp frequently accompanies the
acne, and this must be treated. For this condition the following lotion i
is very good :
i
^ Hydrarg. bichlor gr. i ;
Resorcin 3ii -
Spr. vini rect 3iv
Aquae rosae ad 5'^ >
M. et ft. lotio i
If this makes the hair too dry, a small amount of glycerine, 3i to
3ii, may be added to the lotion. |
Vaccine treatment in acne has proven very disappointing. i
Trimble, in a large series of cases at the New York Skin and Cancer
Hospital, had generally unsatisfactory results.
Figs. 96 and 97. Models in Neisser's Clinic in Breslau (Kroener).
123
Acne Rosacea
Plate 62, Fig. 98
In tliis affection there are acne lesions of a peculiar type plus a
condition of dilated blood-vessels. Both classes of lesion are due
to persistent flushing or congestion of the face and seldom appear
until after the period in which developmental acne has run its course.
The vascular or hyperemic element gives the lesions a peculiar, angry
look. In young subjects pustules on or beside the nose may present
this angry appearance, but there is never any general outbreak.
These rosaceous papules and pustules come and go very rapidly and
suppuration plays a much smaller part than in other common forms
of acne, the typical lesions being macules, papides and tubercles.
Pus formation is usually limited.
The manifestations of this affection differ greatly, for the two ele-
ments may be combined in many ways. The mildest type is confined
to the nose, perhaps only to the tip, and is present as a mere intense
redness, paling on pressure. The lesion may be due to a pustule from
an occluded gland in which case it usually quickly subsides when the
pus escapes. Much more commonly is the red area on the nose a
simple congestion without any glandular implication, and which tends
to persist for an indefinite period. The lack of an acne element in
these cases induces some authors to make a distinction between mere
rosacea and acne rosacea, but the dependence of both lesions on a com-
mon cause is indisputable. Thus the pure rosaceous type is very
commonly associated with oily seborrhea. The entire nose may be
bright red in color without any acne element associated. The redness
comes and goes and in the course of time permanent telangiectases
appear. Redness and oiliness may involve the entire face and is a
matter of physical habit or complexion rather than an actual disease.
In these sMns the sebaceous glands are prominent and are often seen
to be the seat of comedones. Small, scattered telangiectases are seen
here and there. In another type of skin which is finely grained and
free from any predisposition to disorder of the sebaceous glands a
naturally florid skin becomes with advancing years a network of telan-
124
Plate 62.
Fig. 98. Acne rosacea.
Fig. 99. Rhinophyma.
giectases which may reach down upon the neck and involve the ears.
This type shows clearly that rosacea may be entirely distinct from
acne or seborrhea and result from constant congestion.
The diffuse type of acne rosacea is well marked. Certain individ-
uals after a few days' excessive use of liquor and tobacco, which ordi-
narily produce a simple flushing of the face, may break out suddenly
over the entire congested area with acne rosacea. It may appear with
almost the suddenness of a rash, the entire face and forehead being
covered with macules and papulopustules. There are no selective
areas. These cases soon subside with removal of the cause, but if the
latter continues in action the condition becomes steadily aggravated.
The varying element of predisposition is seen in the fact that not all
men who use alcohol have congestion of the face and of those who do,
only a small minority develop acne rosacea.
The most typical form of acne rosacea is diffuse with a tendency
to develop in a special area, to wit, the forehead, middle of the face
and chin. In bald people it may be noted that the lesions on the fore-
head may extend upon the scalp. Acne rosacea seldom appears before
the age of thirty, and it will very often be found that these subjects
have suffered from juvenile acne and sometimes the latter passes
directly into the other form. These patients show combinations of
acne and rosacea. The nose may be the seat of the latter alone, while
the papules show a certain tendency to be aggregated into circum-
scribed patches on the lower portion of the forehead, centre of the
cheeks and chin. This form is essentially chronic or recurrent, due to
deep-seated causes.
In chronic acne rosacea a type of lesion appears which is not seen
in acne vulgaris and which is doubtless a consequence of the pro-
tracted congestion. This is a superficial tubercle or nodule, which
evidently represents a hypertrophy from excess of nutriment. While
it may occur wherever there is a focus of disease, its higher degrees
are almost peculiar to the nose.
Etiologu
Aside from the palpable effects of alcohol the causal elements are
obscure. Occupation is seen in the rosacea of cabmen, resulting from
prolonged exposure to cold with sudden transition to hot rooms, and
the free use of alcohol. The rosaceous element greatly preponderates
over the acne in these. Most of the factors which determine and
aggravate acne vulgaris may be seen in acne rosacea. Chief of these
are digestive disorders and menstrual irregularities. In a number
126
of my cases it has occurred to me that the acne was more or less
related in its etiology to pyorrhea alveolaris. The rosacea seen in
hale old men often indicates defective metabolism incidental to ad-
vanced age and inability or disinclination to change their mode of
life.
Diagnosis
In rare cases in which eczema attacks the acne area a distinction
may be impossible at first. Acne rosacea, however, does not itch and
the skin may be cooler than normal. A hj'perplastic circumscribed
patch of acne may closely simulate lupus of either form or a syphUide
but no real confusion should arise here.
Prognosis
The prognosis with full and proper management is good for recov-
ery and the chance of spontaneous recovery or recovery under half
measures is correspondingly poor.
Treatment
The regulation of the diet and habits is the same as that required
in acne vulgaris. In addition the digestive organs may benefit by
direct treatment of the indigestion which often seems far more in
evidence than in acne vulgaris. The services of a dental surgeon are
often indicated and in refractory cases a gastro-enterologist may
render much service by making an exact diagnosis of the state of the
digestive organs.
Saline purgatives and other derivative and depletive measures,
provided they do not flush the face, often accelerate the reduction of
the congestion of the face. In some cases no impression is made on
the disease untU aU causes of flushing are eliminated. Thus hot
drinks and hot soup at meals have to be forbidden. The frequent
occurrence of rosacea in dressmakers seems due to a combination of
causes which have this tendency, as drinking much hot tea, improper
posture, sewing for hours in front of a hot lamp, etc.
In some cases considerable benefit follows the internal use of
ichthyol. This should be given after meals in doses of from ten to
twenty grains, either in capsules or well diluted in water.
Not much can be accomplished by local treatment, aside from sur-
gical measures, beyond the constant use of a protective sediment-
lotion. The most serviceable application is strong lotio alba. When-
ever the seborrhoic element is very marked, resorcin is specially
indicated.
126
In well-developed forms, much may be done by various instru- I
mental resources — scarification of densely congested areas, elec- j
trolysis of telangiectases, etc, with hot applications to encourage j
bleeding and promote the slow circulation. Hydrotherapy appears '
to exert a favorable influence in restoring the tone of the vessels. j
1
Fig. 98. Model in Neisser's Clinic in Breslau {Kroener).
127
Rhinophyma
Plate 62, Fig. 99
This condition has been termed the third stage of acne rosacea, but
it is best regarded as an independent affection. It is nearly always
confined to males and as the name implies is limited to the nose. Were
it actually the extreme stage of acne rosacea we should expect it to
develop more frequently. As a matter of fact, however, the affection
is a very rare one and may occur in men who have previously had but
little acne. So far from being a mere hypertrophy or hyperplasia,
there is said to be a new formation of fatty tissue. The affection
behaves in every way as a neoplasm, growing to an almost indefinite
extent with a tendency to lobulation and the production of pendulous,
more or less pedunculated lobes at the dependent portion. The his-
tologic picture is a variable one. There may be found aU stages of
inflammation, capillary dilatation, hypertrophy of the sebaceous
glands, as well as granulation and cicatricial tissue.
Trealment
The only treatment is surgical. The lobulated and thickened por-
tions should be removed and the underlying tissue pared do\\Ti to the
cartilage. Healing is prompt and the results are generally satis-
factory.
Fig. 99. Model in Neisscr's Clinic in Breslau {Kroener).
128
Plate 63.
n3
3
O
"3
c
a
O
c
o
o
Dermatitis Papillaris Capillitii
Synonym: Acne-Keloid
Plate 63, Fig. 100
Not much is known of this peculiar affection beyond the fact that
it is limited to the nuchal region at the scalp border, a locality prone
to folliculitis and furuneulosis, and that it often depends on persistent
irritation of the neckband. The earliest lesions bear a considerable
resemblance to those of sycosis barbae when the latter forms nodes and
tubercles ; but there is no evidence that the present affection is a fol-
liculitis. As in sycosis, raw papillary outgrowths appear and form
crusts. The infiltration which causes the nodules and the prolifera-
tion at the surface are attended with a sclerotic and cicatricial
tendency, the latter having a disposition to form a scar keloid. The
lesions are densely aggregated at the nucha, and the various changes
which take place tend to cause atrophy and destruction of the follicles.
This is offset by a tendency of the process to extend upward along the
occiput. The keloidal element is regarded as characteristic of this
affection, and sufficient to distinguish it from any form of folliculitis,
acne or furuneulosis.
Diagnosis
The diagnostic points have already been outlined. Confusion with
any other affection is hardly possible.
Prognosis
For a benign affection its course is singular, persistent and re-
fractory to treatment.
Treatment
Improvement in nutrition and withholding of irritation do not
exert a beneficial influence. Cleanliness, epilation and mild antisepsis
produce surface improvement only. Destruction by cautery and even
excision of the diseased area have been followed by recurrence.
Improvement often follows the protracted use of the X-rays.
Fig. 100. Model in Freiburg Clinic (Johnsen).
129
Granulosis Rubra Nasi
Plate 63, Fig. 101
This affection was not described until 1900 by Luithlen. Jadas-
sohn named it, and made the first important contribution to the
literature, reporting a considerable number of cases. It is believed to
stand in necessary relationship with sweat-glands, so that it ranks
in this respect with hyperidrosis and other functional anomalies of
these organs, miliaria and sudandna and hydrocystoma ; also with
various diseases in which the sweat-glands appear to be involved sec-
ondarily. The affection appears to be peculiar to the face and largely
restricted to the nose. Exceptionally it may extend from the latter
and involve the upper lip or cheeks.
Clinically, it is a form of red nose, which, however, has nothing
in common with acne rosacea, and which, moreover, is almost or
quite peculiar to young children, who seldom or never suffer from
the other malady. Hence a red nose in a child or a yoimg adolescent
should suggest this possibility. Despite the diffuse redness, the
affected skin is seen to be the seat of papules, which remain discrete,
although placed close together. The individual lesions do not exceed
the size of a pinhead, and are bright red or brownish red in color,
paling readily on pressure. It could hardly be confounded with
seborrhea, but resembles to some extent both forms of lupus. There
is no reason for regarding it as a tuberculide. The affection is one
eminently chronic, but destined to be outgrown during late adoles-
cence. It therefore has a developmental element. Thus far the
subjects have been delicate children in the second period of childhood
— from seven to fifteen years. Hyperidrosis often coexists both in the
affected skin and elsewhere, and is regarded as part of the predis-
position. The occasional presence of hydrocystoma also adds
strength to this view. The individual papules appear to undergo
some central suppuration and desiccation. Neither scars nor stains
are left. Little or nothing is known of the intimate nature of the
affection, and no successful remedies have yet been recognized.
Fig. 101. Model in Neisser's Clinic in Breslau (Kroener).
ISO
Alopecia Areata
Plate 64, Fig. 102
This affection is that form of baldness in spots which is not due to
any known form of parasite nor secondary to any other known
affection. Our conception of it is negative rather than positive.
The fact that it may develop with relatively acute symptoms and
involve all or several of the hairy regions of the body is sufficient
to distinguish it from all ordinary local forms of baldness. There
is no essential difference between alopecia areata and the universal
shedding of all the hair which may occur in general diseases and after
profound nervous impressions. This fact, combined with much other
evidence, seems to point to other than merely local causes of alopecia
areata. On the other hand, well-known fungi can produce baldness
in spots, and this, with other evidence, points to a parasitic origin of
at least certain cases. Many authorities therefore speak of two
separate forms of the disease. Aside from the unicistic and dualistic
viewpoints, a compromise view is possible. We may suppose the
cooperation of constitutional or nervous influence weakening the soil,
and a germ of low pathogenicity able to act upon such a soil.
Alopecia areata was evidently well known to antiquity and under
such names as area Celsi and ophiasis receives rather more descrip-
tion than other more important affections. Ophiasis is commonly
spoken of as referring to a serpiginous or creeping form which
denudes the scalp in bands or sinuous tracts. It is, of course, barely
possible that the name comes from the shedding of its skin by the
serpent.
As already implied, the skin itself undergoes no change, and in
the frequent absence of any efficient causes the spontaneous char-
acter of the process suggests something foreordained to occur. The
identity of the circumscribed and diffuse types is paralleled by the
alopecia due to syphilis. As a rule, the loss of hair is confined to
circumscribed areas, comparable in size and shape to prints of the
finger-tips. Exceptionally there is relatively rapid loss of hair in
bulk.
In a very few instances an epidemic incidence of this affection has
been noted. While at first sight this seems conclusive evidence of
contagion, the wholesale occurrence of disease may be due to other
factors, especially those able to act upon the ductless glands.
131
In the majority of cases patients present themselves "nith bare
spots on the scalp, and a history of sudden or more insidious shedding
of the hair. After a lock of hair has been shed, the hairs at the
margin continue to come away until as a rule self-limitation occurs.
Hence the greater the number of the primitive spots, the greater the
likelihood of extensive baldness. In certain cases, however, the
process may extend in a straight or sinuous band, and the balance of
the scalp may or may not be involved. In a third type the baldness
caimot be said to occur in spots, for the hair of one-half of the scalp
may be shed almost en masse. In still another type the marginal
shedding of the hair about the early bald spots may not be arrested,
but may persist until all the scalp hair is sacrificed. It is thus seen
that there are several ways in which the scalp may be largely or
fuUy denuded.
In some of the more acute, diffuse cases of alopecia of the scalp,
shedding of the eyebrows and eyelashes may also occur. This compli-
cation need not indicate a general disposition to shedding of the hair,
because the innervation of the eyebrows is the same as that of part of
the scalp. This is also true of cases in which the beard is involved.
But there are cases of total loss of scalp hair in which the face is un-
affected. In true alopecia universalis the axillary, pubic, and all the
scattered hairs over the surface may be shed. One of the most char-
acteristic features of alopecia areata in general is the well-marked
tendency of the hair to grow in again at some more or less remote
period.
The eyebrows and beard are sometimes involved without the scalp,
and in the former, by reason of their limited area, the different
varieties of shedding may all be studied. In some cases the hair is
simply thinned out, without formation of spots. In others a spot
forms and the rest of the eyebrow remains intact; or the spot may
spread imtU the brows are denuded. There may be an irregular
combination of small irregular spots and thinning which causes an
eroded or moth-eaten look. Finally, the hairs may be shed suddenly
en masse. There is no doubt that all these modes of shedding occur
in the scalp and elsewhere. Therefore the initial bald spots are not
necessary steps in the development of the disease but only the
commonest step.
When patients with alopecia areata present themselves late in the
evolution of the disease decided attempts at regeneration of the hair
may be noticeable. An old, self-limited patch may be the seat of a
downy growth, or pigmented bristle-like hairs may be sparsely pres-
182
ent. In certain cases opportunity is afforded to see the shedding of
this second growth.
A pertinent question refers to whether or not cases of apparent
parasitic or internal origin exhibit any differences in symptom-
atology. This question does not seem to be answered fully by authors
and but little data are available for this purpose.
Etiologi/
The association of certain cases of alopecia areata with psychic
and nervous factors is unquestionable and a long series of examples
is given by all systematic writers. It is to be feared, however, that if
all such cases could be added together they would make only a small
fraction of the total material. There is also much variation among
these psychoneurotic factors. Some are examples of psychic shock,
and it is not a simple matter to connect this factor with the innerva-
tion of special areas of the scalp. In physical injury the psychic
element is doubtless paramount, but there are not a few cases which
have followed various injuries of the scalp itself. In a few instances
alopecia areata has been seen as a familial disease, which almost
amounts to a demonstration of some sort of transmissible inferiority
or biological anomaly. The best-marked examples of a neurotic
factor are those in which a direct or reflex disturbance of innervation
may be inferred. Eye strain and dental lesions, particularly the
former, may be mentioned here as possible causes. On the other
hand, anomalies of the hair, eyes and teeth may be associated together
on developmental grounds. In certain cases, however, the crucial
test of treatment seems to point to the presence of a neurotic factor.
At the other end of the etiologic scale may be mentioned the
parasitic element. In a relatively small percentage of cases this
seems to be imdoubted or probable. The few accounts on record of
epidermic incidence point in the same direction. The dilemma which
confronts us is whether to assume that all cases are parasitic, on
the one hand, or to attempt to isolate a special contagious form of
disease. Of the two the latter seems to be the safer course. For
the past seventy years, or almost as far back as clinical microscopy
extends, authorities have claimed the discovery of the parasite of
alopecia areata. At present it is evident that no one microorganism
can be accused. There is much evidence in favor of any one of three
or four kinds, including bacilli, cocci and fungi, the latter indistin-
guishable from the ringworm fungi. Several observers assert that a
slight inflammation of the corium is always at the bottom of alopecia
areata ; in common with other obscure affections, the latter has been
183
attributed to a periarteritis or thrombosis of the nutrient blood-
vessels.
Diagnosis
Alopecia areata has to be distinguished from all other forms of
baldness in spots and in fact baldness of any sort. Ordinary baldness
begins as a bare spot on the crown and a localized loss of hair on the
temples high up. Some of the symptoms are much the same, for
example, shedding of hair on the pillow, etc. The only lesion of an
alopecia areata may chance to be on the crown. Both forms are under
general and nervous influence to some extent, and in both there may
be attempts at regeneration, although in ordinary premature bald-
ness these are practically never successful. In ordinary premature
baldness we may isolate certain types "which have nothing in common
with alopecia areata, but there is a residue of cases in which this
separation is not so easily effected. Much that would be termed
alopecia areata represents a gradual thinning or a copious irregular
shedding, and some cases show no tendency to regeneration ; so that
we are forced to ask if premature baldness may not begin at times
as alopecia areata. In sj-philitic alopecia the bald spots are smaller
than those of alopecia areata, and other sjTnptoms of syphilis are
generally present.
There remain for consideration only the bald spots due to kno-ftTi
parasites — the trieophyton. This may sometimes denude the scalp
cleanly of hair. In such cases hairs at the margin of the bald spots
should come away readily and show the presence of parasites.
Secondary baldness from destructive lesions and wounds should be
readily recognized, for the follicles have been obliterated.
Prognosis
There is quite a pronounced tendency to spontaneous regenera-
tion, especially below a certain age limit, which is placed at about
forty years. This is offset, however, at times, by the inferior char-
acter of the second growth, which may also faU out anew. In cases
of prompt, complete regeneration, we are once more reminded of a
physiologic shedding of the hair, or rather of an occurrence in brief
time of a process which goes on normally more or less imperceptibly.
On the other hand, ordinary premature baldness may perhaps
appear as alopecia areata, and in such cases no regeneration is to be
expected. Prognosis should be guarded, but encouraging the patient
■will lead him to take pains with the treatment, and the prognosis
with good treatment is naturally much improved. Extensive, rapid,
generalized alopecia, especially after the age of forty, gives a bad
134
prognosis. Patency of follicles and presence of downy hairs are of
good prognostic significance. Blistering a small area in a bare spot
win sometimes cause the sprouting of a tuft of good hair. This test
is usually a good prognostic, although it cannot be relied on
implicitly.
Treatment
As in any affection with an inherent tendency to self-limitation
and regeneration, numerous plans of management and individual
remedies have gained an ill-merited reputation for curative proper-
ties. If the hair is still being shed it is well to use constitutional
measures, tonics and nerve stimuli. Arsenic, phosphorus, nux
vomica, iron, piloearpin, etc., one or several, may be pushed and the
various electric currents may be employed. On the same general
principle errors of refraction should be corrected with proper glasses,
carious teeth be filled, etc. On the supposition that a parasite is
involved, the patient must be protected from auto- and heteroinfec-
tion. The scalp should be washed frequently with parasiticides, and
the patient should use only his own set of combs and brushes, which
should be kept clean.
The actual direct treatment consists of stimulating the scalp to
secure a new growth of hair. The stimulating remedies may also
figure as parasiticides, so that the double indication may be filled
with a single prescription, one, for example, containing sulphur and
Betanaphthol. This plan is for the entire scalp, but for the individ-
ual bald spots, especially when the latter are of some age, intensive
local treatment is indicated. This also applies when a large area of
denuded scalp or the entire scalp is involved.
While applications of every grade of severity, short, of course,
of destroying the follicles, have been employed for this purpose, it is
doubtless best to apply at the outset one of the stronger remedies —
chrysarobin in full strength, pure carbolic acid, tinct. cantharides,
tinct. capsicum, corrosive sublimate, oil of turpentine, etc. The de-
sired effect is vesication. Cantharidal collodion, equal parts tinct.
cantharides and glycerine, pure carbolic acid, pure lactic acid are effi-
cacious. One good application should be sufficient. A period of about
two weeks is required for the sprouting of new hairs. Excellent
opportunities are offered for control studies, as several vesicants
may be tested simultaneously. The local treatment of alopecia areata
is resolved practically to using a succession of the most efficacious
vesicants, going from one region of the scalp to another.
Fig. 102. Half-tone, Dr. Kingsbury, of New York.
135
Alopecia Congenita
Synonyms: Alopecia adnata, Hypotrichosis, Universal congenital atrichia
Plate 65, Fig. 103
Congenital alopecia, a very rare condition, is characterized by a
partial or total absence of hair at birth, or a short time thereafter. It
is occasionally accompanied by defective development of the teeth
and nails. The hair loss may be patchy in character, or the hair
growth scanty and marked by the appearance of lanugo hairs or dowTi.
The eyebrows, and later in life the axillae or pubes, may, or may not,
be affected. Many individual cases of so-called hypotrichosis are
seen at a very late period, and it is then not always possible to
exclude an early infection of the scalp, with secondary hair loss.
Occasionally nail dystrophy is the most important feature, the hair
being involved to a less extent. Defective development of the teeth
may exist in all gradations, from a few misshapen and irregular teeth,
to total edentation. Other abnormal conditions, sometimes associated
with hypotrichosis, are diminished or abolished secretion of tears
and sweat.
Etiologi/
The condition is due to a congenital anomaly in the development
of the hair pouch from the epiblast, and heredity is the most impor-
tant factor in its causation. The disease has frequently been traced
through several generations in the same family. Nicolle and Ealipre
knew of no less than thirty-six cases of hair and nail dystrophy in
six generations. In the three cases illustrated (Fig. 103), the
maternal grandfather had the same disease. The father of the ma-
ternal grandfather was said to have been bald all of his life and
two of his brothers were also absolutely devoid of hair.
Diagnosis
Alopecia areata, which at times may resemble it, begins later in
life, occurs in roimd or oval, well defined areas, which soon show
186
evidence of the return of hair. Even when complete, there is a
history of its beginning in areas.
Prognosis
This is unfavorable in the great majority of instances.
Treatment
Any underlying constitutional disturbance should be corrected.
The local treatment should be of a stimulating character.
Fig. 103. Half-tone, Dr. Kingsbury, of New York
187
Vitiligo
Synonym : Leucoderma
Plate 66, Fig. 104
This affection represents a disappearance of pigment in patches
■with a tendency to increase peripherally. Just external to the patch
there is usually an increased deposit of pigment, so that the affec-
tion is rather a dyschromatosis than a mere atrophy. VitUigo is
neither to be confounded "with congenital absence of pigment, nor
with secondary loss of the same.
The disease tends to appear not only on exposed regions but also
on the trunk. In the black race, the peripheral hyperpigmentation
is seldom noticeable. The spots, rounded in contour, enlarge and
coalesce. The skin is otherwise absolutely xmchanged. The hairs —
eyebrows, for example — usually turn white when involved in a patch,
but in some cases remain unchanged. In certain cases a peculiar
illusion is produced, as when the affection has extended over an entire
area, save a few islets of normal skin. Here the white color may
seem the normal shade, while the normal skin imposes itself as
chloasma or some similar pigment anomaly. This illusion is not
uncommon in a very chronic case of vitiligo on the backs of the
hands, which is a favorite seat for the affection.
Etiology
The affection is evidently very deepseated. It is common in dark
races, and may be inherited. Mixture of race may conduce to it,
although some of its extreme manifestations occur in pure-blooded
negroes. Psychic shock, nerve injuries and local irritation appear
to have initiated the process in a few cases. It is claimed that the
pigment is originally increased before it disappears. This would
account for the outlying pigmented zone.
Diagnosit
The affections which might cause confusion have in part been
mentioned. If there is any confusion with chloasma, or other dis-
188
Plate 66.
TO
E
CJ
in
o
o
o
coloration, the presence of the scalloped convex border of vitiligo
will usually dispel it. In leper countries, and especially among
dark races, vitiligo is often confused -with leprosy, especially so as
non-pigmented patches often occur in anesthetic leprosy. Syphilitic
leucoderma, so-called, occurs on the neck, and nearly always in
women.
Prognosis
The affection, while progressive, seldom or never becomes imi-
versal. Not only is its march very slow, but it eventually ceases.
Treatment
Arsenic, nux vomica, phosphate of zinc and other nerve tonics are
recommended on theoretical grounds. The only satisfactory local
treatment consists of cosmetic measures designed to diminish the
contrast between the patches and the normal skin.
Fig. 104. Model in Neisser's Clinic in Breslau {Kroener). On the abdo-
men there are two urticarial wheals.
139
Chloasma
Plate 66, Fig. 105
While this term is used somewhat as a synonym for hyperpig-
mentation in general, it is best restricted here, as it is in the clinic,
to a single condition known as chloasma uterinum, this being a
definite, common and well-characterized affection. In passing, it
may be stated that hyperpigmentation is due both to external and
internal causes. The former class include all darkening of the skin
from exposure to the weather, and from chemical, thermal, and
mechanical irritation. The latter, also termed symptomatic, include,
besides chloasma uterinum, many forms of pigmentation from gen-
eral diseases, especially Addison's disease, malaria, and cachexise in
general, and from certain drugs, as arsenic.
Chloasma uterinum, so-called, is, as the name implies, peculiar to
women, and especially to pregnant women. It is usually limited to
the face, and much more pronounced in brunettes. Exceptionally it
is seen on the trunk and limbs. On the face, the site of choice is
the forehead, and in non-gravid women it is often limited to that
region. It sometimes covers the entire face, as "ndth a mask, and
this is perhaps oftener seen in pregnancy, or at least the "mask of
pregnancy" is a common expression. The lesions occur naturally in
small irregular blotches, with a strong tendency to become confluent.
The color varies from yellowish to deep broAvn, and in the less marked
degrees is hardly distinguishable from freckles. The affection does
not involve the epidermis, the skin being of normal texture.
Etiology
The appearance of chloasma in the gravid woman is usually con-
nected with the deepening in color of the areolae of the nipples and
linea alba. From this view^joint it should be almost physiologic.
Others regard it as a mild manifestation of the toxemia of pregnancy.
But since it often accompanies uterine and ovarian diseases in the
non-gravid, it may also be called a reflex, although the rationale is
140
unknown. Finally, it occurs in women not known to have utero-
ovarian disturbance, and is then attributed by the laity to biliousness.
From the fact that it is peculiar to women, and women during the
menstrual cycle, and that it appears in pregnancy to vanish after
delivery, and also stands in a similar causal relation to utero-ovarian
diseases, it evidently stands in intimate association with the repro-
ductive cycle. In women the affection may exceptionally be almost
universal.
Diagnosis
On its usual site, the face, chloasma could hardly be confounded
with any other discoloration except chromidrosis. In other localities,
unless also present on the face, diagnosis might prove very difficult.
It might be necessary to exclude various other pigment anomalies and
stains. For confusion with vitiligo, see account of the latter.
Prognosis
Although chloasma in the gravida disappears with the cause, this
is not necessarily the case with chloasma in the non-gravid, although
it is common enough, especially when the discoloration appears to
stand in close relationship with some pelvic lesion. Wlien no such
relationship is in evidence there may be no tendency to disappear.
Treatment
The management comprises, first, attempts to remove the cause —
for example, ovarian dysmenorrhea. The other resource, which is
purely cosmetic, is removal of the discolored cuticle by vesicants.
Not all the pigment may come away, but the balance will probably
be absorbed. However, the trouble may readily recur. Of various
preparations used as vesicants may be mentioned corrosive sublimate
in 5% aqueous solutions, saturated solution of salicylic acid in
alcohol, and salicylic acid collodion.
Fig. 105. Model in the Freiburg Clinic (Johnsen). Ninth month of
pregnancy.
141
Naevus Vascularis
Synonyms: Nsevus sanguineus, Port-wine mark — Mother's mark
Plate 67, Fig. 106
These differ radically from nsevi vernicosi in being neoplastic,
the latter ranking only as hypertrophies. Technically they are angio-
mata of various types with the exception of the telangiectases, which
are usually held to be acquired as the result of long-continued conges-
tion, active or passive. The number of clinical forms is very
considerable. In some cases large naevi are present at birth upon the
head or face, and on account of the disfigurement are often removed
at a very tender age. They may grow rapidly and become pulsatile.
In certain instances they disappear of themselves. There is some
danger of injury, hemorrhage, infection and sloughing, also of certain
regressive changes. The second familiar type is the port-wine mark,
a flat formation having a red or livid hue. These birth marks differ
greatly in size and shape and coloration, hence their supposed resem-
blance to strawberries and other objects and their supposed depen-
dence on maternal impressions.
Etiology
Beyond the possibility that these formations have an embryonic
origin, but little is known of their intimate nature. An alternate
view is the dependence on amniotic adhesions.
Diagnosis
These neoplasms should be readily recognized.
Prognosis
If the tumor is growing rapidly or is pulsating, the possible out-
come has already been alluded to. The mother's mark form does not
undergo any changes.
Treatment
Small angiomata may be destroyed by carbonic acid snow, radium
electrolysis or chemical caustics. Large growths are usually treated
U2
Plate 67.
Fig. 106. Naevus vascularis.
Fig. 107. Naevus linearis.
by operating surgeons. Port-wine marks are usually treated with
electrolysis, but this does not cause the total obliteration of the mark,
the latter only paling somewhat. Good results are sometimes
obtained by the use of carbonic acid snow.
Fig. 106. Model in Freiburg Clinic (Johnsen). A girl, seventeen years of
age, with an enormous navus flammeus covering nearly the entire half
of the body, and leaving but little healthy skin.
143
Naevus Linearis
Plate 67, Fig. 107
While this type does not differ much in structure from naevus
verrucosus, there is often a special development of the horny layer.
In other cases the warts of which it consists have a discrete papillary
formation which closely simulates an eruptive affection. The chief
characteristic of the linear naevus is the close agreement of its area
of distribution wdth that of the cranial or spinal nerve for the
area. This causes them to assume a linear or rather band-like outline
upon one half of the body. The nature of this localization is by no
means apparent. A neurogenous theory is not necessary, for it may
be shown equally that the naevi follow the metameric segments,
embryonic sutures, lines of skin cleavage, etc. In other words, the
mischief has evidently been done before the nerves have been differ-
entiated. As a rule these formations are extensive, occupying half
the face, or neck, etc.
Treatment
Chemical caustics are often employed for the removal of the
growths, but better results may be obtained by the use of the sharp
curette.
Fig. 107. Model in Neisser's Clinic in Breslau (Kroener).
Plate 68.
Fig. 108. Naevus papillaris pigmentosus.
Naevus Papillaris Pigmentosus
Plate 68, Fig. 108; Plate 69, Fig. 109
Most writers make a special group-affection known as nsevus
pigmentosus, which they subdivide into flat, hairy and warty types.
The two first-mentioned appear to represent abortive forms in wliich
the new formation is limited chiefly to the pigment cells and hairs.
The resulting hypertrophy is simply a flat, smooth pigmented disk of
variable size, with or without the presence of a certain number of
bristle-like hairs. In the verrucous form, on the other hand, the
entire thickness of the skin may be involved in the hypertrophy,
especially the papillary layer of the corium. The pigment cells and
hair usually participate, so that a large or small, warty, uneven
patch is formed, almost always pigmented and piliferous. If the
connective tissue participates the growth usually contains much fatty
tissue, and may hang loose upon the skin. The favorite localities for
all these overgrowths are the head and face, neck and upper part of
the trunk. As a rule the particular area involved appears to possess
no special significance, although an exception must be made of the
linear, unilateral type. Aside from this type the formations may
vary greatly in size, shape and number, and no laws can be laid down
for their distribution. They may be of the finest size or may occupy
the entire shoulder area.
Etiology
As a rule they are spoken of as congenital, although not neces-
sarily actually present at birth. There can be but little doubt as to
their embryonic origin.
Diagnosis
These overgrowths are absolutely typical and can never be
confused with any other condition.
Prognosis
They attain a certain growth and have no tendency whatever to
disappear. In rare cases they form the starting point for malignant
melanotic tumors (Fig. 109),
145
Treatment
Wide excision is the most satisfactory treatment, as the possibility
of malignant degeneration is thereby discounted. This, however, is
often impracticable, for several reasons. Small moles may be re-
moved by caustics or electrolysis, the latter also being indicated to
destroy the grovrth of hair. For extensive formations, it may be
necessary to proceed piecemeal, levelling the surface with curved
scissors, and cauterizing the exposed surface.
Fig. 108. Model in Neisser's Clinic in Breslau (Kroemr),
Fig. 109. Model in v. Bergmann's Clinic in Berlin (Kolbow).
146
Plate 69.
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Adenoma Sebaceum
Plate 69, Fig. 110
This rare affection is classed with new growths to-day, although
at one time it was placed among the nsevi, of which it was supposed
to represent a papulovascular type. It develops from the sebaceous
glands of the face, its highest development occurring at the sides of
the nose. The new growths, varying in size from a pinhead to a
small pea, are very numerous and closely aggregated. They are
either devoid of special color or are red or broAvn in hue, these
shades depending on a vascular or pigment component. They are
congenital, although not necessarily visible at birth. Like all con-
genital hypertrophies or neoplasms, their appearance may be delayed
for years. They may be associated with other malformations and the
patients are generally of a low grade of mental development.
Diagnosis
These lesions may simulate a number of affections, especially of
the sebaceous glands — acne rosacea, multiple benign cystic, epithe-
lioma, moUoscum contagiosum, and colloid milium. It should,
however, be possible to exclude all of these without much difficulty.
Treatment
This affection is well adapted to electrolysis. Another resource
is the production of exfoliation by any vesicating application.
Fig. 110. Model in Neisser's Clinic in Breslau {Kroener).
147
Ichthyosis Simplex
Plate 70, Fig. Ill
Essentially a hypertrophy of the horny layer of the epidermis,
this condition also represents a defect because of the abolition of
the cutaneous secretions. It is not certain whether the latter is due
to pressure atrophy or whether both atrophic and hj'pertrophic
features belong to a single dj^strophic condition. Ichthyosis simplex
may be present in varj-ing degrees, and the overproduction and char-
acter of the scales often suggest the skin of a fish or reptile. The
sjTnptomatology, therefore, varies with the case, to such a degree that
different cases may resemble one another but slightly or not at aU.
In the very mildest form the skin feels and appears dry and does
not perspire. The hair-foUicles may form small firm papules on the
upper arms, thighs, etc., giving the appearance of permanent goose-
skin. Such integument has been Likened to a nutmeg grater. The
condition is similar to that seen in lichen pilaris, an affection which
can exist without ichthyosis. This degree of the disease is character-
ized by slight desquamation. A prominent feature is that it is not
much in evidence in warm weather, but returns again with the
approach of wTnter. Hence remedies may be believed to have cured
eases which improved spontaneously. '\^lien skins of this sort are
treated with inunctions of oUy matter, they may appear natural for
the time. In these mild cases the regions of preference are the ex-
tensor surfaces of the extremities, but unnatural dryness may be
made out on the back and elsewhere. In cases of higher degree a
tilelike arrangement may be noted, corresponding in part to the
natural folds of the thickened skin. However, there is also a cleavage
in the opposite direction, so that the skin is mapped out into poly-
hedral areas, suggesting strongly a retrogression to the fishes and
reptiles. In the highest degrees of hypertrophy of the scales, there
is some tendency to the formation of fissures, while the low vitality
appears to predispose to other affections.
148
Etiology
Ichthyosis is eminently a congenital affection, as shown by occa-
sional familial incidence, and doubtless originates at an early period
of intrauterine life.
Diagnosis
Well-developed ichthyosis simplex is unmistakable. But mild de-
grees are readily confounded with other kinds of dry skin, inherited
or acquired. The history of ichthyosis, when one is obtainable, will
be sufficient — appearance in early childhood, improvement in warm
weather, etc.
Prognosis
As a deformity, ichthyosis may exceptionally in mild forms be
outgrown. It may be kept down by treatment. Otherwise it is
incurable. -
Treatment
The skin must be kept soft, all accumulated scales to be first
removed. Alkaline baths, soap and salicylic acid all conduce to the
latter end. The best emollient is probably glycerole of starch,
although lanolin should be valuable. Of specific remedies, sulphur
and resorcin have been praised.
Fig. 111. Model in Freiburg Clinic (Johnsen). The transitions from the
slightest grade of Ichthyosis simplex to the fully developed Ichthyosis
serpentina are beautifully rendered in this picture.
149
Ichthyosis Hystrix
Plate 71, Fig. 112
This affection is regarded by some authorities as an advanced
degree of ichthyosis simplex, but such a view seems hardly tenable,
because of the localized character of the alterations, -which often have
a purely Uneal grouping. However, the two forms are often seen
side by side, and in some severe types of ichthyosis simplex a few
of the lesions of hystrix appear here and there; while on the other
hand this apparent unity of nature is shattered by cases in which the
severest forms of hystrix appear on smooth, supple skin. In this
type of cases we are reminded irresistibly of linear nsevi of an
unusually horny quality, and the histological examination shows
practically no indifference between hystrix warts and ordinary
acquired verrucae vulgares.
Like ichthyosis simplex, hystrix occurs in various degrees, types,
shades of color, etc. When the lesions are very acuminate, they
suggest the spines of a porcupine ; when flattened, they are likened
to the bark of a tree, etc. Hystrix does not properly occur in large
diffuse sheets, and if this alteration is present, as when an entire
foot and ankle are involved, the condition is usually classed under the
severest type of ichthyosis simplex. Linear hystrix shades imper-
ceptibly into a group of affections in which hypertrophy of some of
the cutaneous structures is often associated with the distribution of
one or more spinal nerves.
Etiology
While clinically by no means the same condition, whatever has
been said concerning the congenital nature and histology of ichthyosis
simplex wiU apply in a measure to hystrix, although in the latter the
structure of common warts is parallel, i.e., the rete is involved
in proliferation as well as the horny layer, and tends to dip into
the interpapillary spaces, while the papUlae show more or less
hypertrophy.
150
Plate 71.
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Treatment
This is summed up in a few words. The horny masses must be
dissolved by strong alkaline solutions (liquor potassae) or strong
salicylic acid ointments. The hypertrophied papillse must now be
destroyed by curettage or caustics, and if the patient does not object
to the scarring which in time follows this practice, the prognosis is
notably better than in ichthyosis simplex.
Fig. 112. Model in Freiburg Clinic (Vogelbacher). Very pronounced cast
of Ichthyosis hystrix. Palms and soles are strongly involved.
151
Ichthyosis Congenita
Plate 72, Fig. 113
This affection is very rare, and not all cases so termed deserve
this title, for they simply represent exfoliation of the skin of the
newly born from other causes. That ichthyosis congenita is of little
practical significance well appears from the fact that such children,
often prematures, usually perish within a short time. The affection
is one of fetal life, and at birth the integimient is hopelessly involved
and has even undergone marked retraction, so that ectropion occurs
and the condition of the mouth makes nursing impossible. The
thickened epidermis fissures in various directions and the peculiar
appearance has caused the patient to be termed "harlequin fetus."
The condition is not to be confused with one characterized by an
unusual quantity of hardened vernix caseosa which cracks in a similar
manner. The subjacent skin in this condition is normal, save that
the fissures may sometimes involve it to some extent. However,
unless promptly removed by inunctions, the deposit may lead to the
death of the newly born by interference -with nutrition and thermo-
geuesis.
Fig. 113. Model in Neisser's Clinic in Breslau (Kroener).
152
Plate 72.
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Keratosis Pilaris
Synonym: Lichen pilaris
Plate 72, Fig. 114
This affection represents an hypertrophy of the corneous layer of
the epidermis about the hair-follicles. The regions involved are
confined largely to the backs of the arms and outer, posterior aspect
of the thighs. The papules are skin-colored, reddish or darkish, and
are often transfixed by a broken hair. They are closely studded
together, but not grouped, suggesting the prominences on a nutmeg-
grater.
Lichen pilaris is hardly a disease in the ordinary sense of the
word, but a deformity. It may be confused with goose-skin, a transi-
tory affection produced by muscular spasm, and patients may consult
physicians for cosmetic reasons. In its mild forms it is by no means
uncommon. Like ichthyosis, it begins to be conspicuous in cool
weather, and is at its best in summer.
Etiology
It seems to be a feature of a preternaturally dry skin, such as is
usually congenital, but may come about from actual disease or from
too much use of soap and water.
Diagnosis
This is seldom difficult, although the affection has doubtless been
confused with lichen scrofulosorum and pityriasis rubra pilaris.
Prognosis
This depends largely upon the attention given to treatment.
Treatment
Frequent bathing in warm water is indicated, and the use of
green soap and a rough wash cloth generally removes the horny
plugs. Anointing the skin with a bland oil or fat at the time of
163
bathing is useful. The following is an agreeable and effective oint-
ment for this purpose :
IJ Acidi carbolici 9i
Boroglycerini 3ii
Lanolini ^
Ungt. aquie rosae Jiii
M. et ft. ungt.
Fig. 114. Model in Neisser's Clinic in Breslau {Kroener),
154
Plate 73.
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Fibroma Molluscum
Synonyms: MoUuscum fibrosum, Molluscum pendulum
Plate 73, Fig. 115
This term is applied alike to one or a few of the soft pedunculated
tumors of the skin, to the massive lesions which form a clinical type
of elephantiasis, and to a generalized fibromatosis in which the entire
surface may be more or less thickly covered with tumors of various
sizes. The growths have to attain a certain size before they can hang
down, so that all below a certain size are sessile, and project but little
beyond the surface. The pendulous property, however, is dependent
on something besides the weight of the mass, for the size of the
attachment is all important. The broader the latter the less the
tendency to hang down. Conversely, a very minute tumor with a
narrow insertion will hang down. In generalized fibromatosis nearly
all of the tumors are sessile. There is both a tendency to grow and to
be arrested, as shown by the great variation in size. The large ele-
phantiastic tumors usually appear on the head or neck, otherwise the
trunk is the favorite locality both when lesions are few and when they
are numerous.
Etiology
This affection is to be regarded as a deformity rather than a
disease. It may run in families, and its nearest congeners are other
benign tumors, such as lipomata and neuromata. They do not
destroy life, but may cause great discomfort and incapacity when very
large or numerous.
Treatment
In certain cases arsenic appears to have some influence in decreas-
ing the size of the tumors. The larger tumors should be removed
by excision or ligature.
Fig. 116. Model in Lassar's Clinic in Berlin (Kasten).
150
Dermatomyoma Multiplex
Plate 73, Fig. 116
This is a rare affection, the diagnosis of which can only be
established fully vrith the microscope. It is a multiple benign neo-
plasm, composed in part of smooth muscle fibres. A variable amount
of fibrous tissue is associated, so that in certain cases fibromyoma is
the proper designation. The tumors are seated for the most part on
the limbs and may be discrete, but are usually grouped. Their color
varies from that of the skin to pink, red and reddish-brown. They
do not exceed the size of a pea, are firm, somewhat flattened, round
or oval, and in some cases quite painful. Most subjects who present
these lesions are adidt females. The causes are entirely tmknown,
and the debut is insidious. A probable diagnosis can be made from
the color and the subjective sensations. These growths never become
malignant, and never ulcerate or undergo any notable degree of
degeneration. They sometimes disappear spontaneously.
In addition to the multiple form, solitary myomata also occur in
the scrotum, vulva and nipples. These may attain a considerable
size. The only treatment for dermatomyomata is excision.
Fig. 116. Model in collection of Prof. Touton in Wiesbaden.
156
Fig. 117. Verrucae vulgarcs.
Fig. lis. Papillomata (condylomata acuminata).
Verruca Vulgaris
SynonjTn : Common warts
Plate 74, Fig. 117
These represent a circumscribed hypertrophy of the papillary
and epidermic layers of the skin, and are invariably acquired,
although similar to congenital warts in structure and appearance.
They may be flat or pointed, have a wide sessile base or be filiform
with narrow attachment. They occur by preference on the hands,
but also are common on the soles of the feet, between the toes, etc.
In these localities they are related to ordinary corns and callouses
and have the same causation. These callous warts occur much more
infrequently than corns and callouses. A third locality for warts to
develop is the scalp, where they may be very numerous. Common
warts of the hands sometimes appear to have a primary lesion or
mother wart, from which others develop. They may be very numer-
ous, and sometimes become aggregated to form a large mass.
Etiology
Warts on the hands, which constitute a well-marked clinical
variety, are almost peculiar to the young, when they appear in crops.
Isolated warts are seemingly of a different nature and may result
from mechanical irritation at any period. Warts apparently arise
from inoculation and autoinoculation. They may come and go
rapidly, despite the fact that there is a much greater disposition to
appear slowly and remain stationary. When warts are removed from
one hand they sometimes disappear from the other. We know nothing
as to the contagious element, but it should resemble that of molluscum
contagiosum. A long incubation period is required, measured some-
times by weeks and even months. The microbic cause should operate
by an ordinary irritation.
Diagnosis
Common warts can hardly be confounded with anything else;
but since certain forms of irritation of the skin may cause a wartlike
growth, it may be well to bear this fact in mind, for different proc-
esses, even epithelioma, begia as ordinary warts, although late in
life.
Treatment
A tendency to warts is believed by some to yield to a course of
arsenic, others advise the administration of repeated doses of sul-
phate of magnesia.
Various forms of local treatment are recommended : surgery, elec-
trolysis, caustics, and keratolytic applications. The high frequency
spark is often effective but it is always exceedingly painful and on
the whole the more primitive therapeutic measures are to be pre-
ferred. The application of a twenty per cent, salicylic acid plaster
or of salicylic acid in collodion (3ss to 3ii) softens the horny part
of the wart and greatly facilitates its removal "\Adth the sharp curette.
Touching the base with the nitrate of silver stick will generally
prevent recurrence. Nitric acid should not be used as it sometimes
produces keloidal scars that are quite as disfiguring as the original
lesions.
Fig. 117. Model in Neisser's Clime in Breslau {Kroerter).
158
Papillomata
Synonym: Condylomata acuminata
Plate 74, Fig. 118
These are the so-called venereal or gonorrheal warts which have
no relationship with any other form. They are virtually peculiar to
the mucous and cutaneous surfaces of the genitals of both sexes, but
could doubtless occur in any locality under precisely the same condi-
tions. Thus they have been seen on the thighs at considerable
distance from the genitals, and even in the axillse and navel. No
precise causal agent has ever been isolated, least of all the gonococcus.
Were the latter the cause it would not be easy to account for the high
degree of immunity often seen. The contagious, autoinoculable na-
ture of these warts may be seen in the evolution of the latter; as
when, for example, they develop in the anus after the latter is exposed
to the secretions of warts in the vulva. The warts may be dry or
bathed in a contagious gonorrheal secretion.
They usually appear on the inner side of the prepuce and glans,
as the characteristic thin, pointed coxcomb-like vegetations, and on
the corresponding regions in the female. There may be only a few
warts or they may be so numerous and confluent as to produce strik-
ing deformity. In the male we may see paraphimosis develop, while
in women the entire vulva may be so covered with them as to occlude
the vaginal entrance. One of my first obstetrical cases as a medical
student occurred in a woman suffering from this condition to a
marked degree and I still retain a vivid recollection of the very
protracted second stage of that particular labor.
Etiology
It is unknown how far this affection has a special contagious prin-
ciple and whether it passes directly from one sex to the other, or only
through the medium of gonorrhea.
169
Diagnosis
The only affection with which these warts could be confounded
is hypertrophic mucous patches. The term cauliflower excrescence^
has been applied to high degrees of each kind/but practically belongs
to the former. The association of the two processes is perhaps
responsible for this confusion. ,i|
Treatment m
MUd cases usually subside rapidly under cleanliness and a strong J
astringent like glycerotannin. In higher degrees the warts are much I
firmer and more highly organized, so that surgical measures are
usually required. One of the most common plans is excision with
scissors followed by the application of the galvano-cautery to the
base. Some authorities seem to regard this as unnecessary and prefer
to use strong caustics like nitric acid, applied in serial sessions.
4
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Fig. 118. Model in Freiburg Clinic (Johnsen). A servant girl, nineteen
years of age. Gonorrhea not established.
!
160 !
Plate 75.
Fig. 119. Verrucae seniles (cavernomata senilia).
Verruca Senilis
Synonym: Senile warts
Plate 75, Fig. 119
The seborrheic warts which appear in the elderly are sometimes
accompanied by another type of senile new-growth, the cavernomata.
These are really small angiomata, the papular capillary varices of
old people. Aside from their occurrence in late life, wherein they
resemble telangiectases, they may be considered in the same class of
growths as ordinary angiomata. These lesions, like the seborrheic
warts, are most frequently situated on the chest, abdomen and back,
often very abundantly about the shoulders. The latter lesions some-
times show a bandlike management (Fig. 119). They vary in size
from a quarter of an inch to one inch in their long diameter. At first
they are light brown in color, but later they become gray or brownish
black. The surface is scaly and slightly granular.
Diagnosis
There should be no difficulty in recognizing either the verruca or
the cavernomata.
Prognosis
The possibility of malignant degeneration should be borne in
mind.
Treatment
As the verruca are quite superficial, the best results are obtained
by the use of the sharp curette. The cavernomata should be excised
or left entirely alone.
Fig. 119. Model in Neisser's Clinic in Breslau (Kroener). On the lower
part of the back is a carcinomatous tumor in course of development.
161
Keratosis Senilis
Plate 76, Fig. 120
This condition is most commonly seen on the back and face in
middle-aged and elderly subjects. In these they present different
features from the flat warts in children, o'vsang to their peculiar
covering. The verrucous part is flat or slightly papillomatous, and
covered by a dark sebaceous or horny crust. The lesions seem inter-
mediate between warts and moles. In size they range from a split
pea to that of a finger-nail, and may be single or multiple. In many
cases they appear to represent the earliest stage of an epithelioma.
If the crusts are detached they at once reform. The diagnosis should
be easy, save for the question of a possible beginning epithelioma.
Treatment
These formations yield readily to the X-rays. It is better treat-
ment, however, to curette or excise the growth.
Fig. 120. Model in Freiburg Clinic (Vogelbacher) . On the upper lip and
on the cheeks several incipient small epitheliomata, which yielded
promptly to X-ray treatment.
162
Plate 76.
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Xeroderma Pigmentosum
Plate 76, Fig. 121
This affection, first recognized and named by Kaposi (1870), is a
very rare and eminently familial malady, which may be roughly
characterized as a congenital defect of the skin that simulates the
ordinary senile integument, and undergoes changes seen in the latter
with a special tendency to malignant degeneration. An important
question relates to the identity of the atrophic, hypertrophic and
degenerative changes of this affection with the same lesions occurring
under more familiar circumstances, and the consensus of opinion
answers in the affirmative. In infancy and early childhood it is only
noted that the patients have a thin, dry skin which freckles easily
and is easily irritated. Macular atrophy and telangiectases develop
later. In the course of years, perhaps much earlier, the freckles are
seen to be undergoing changes into flat pigmented naevi and verruca?.
Retraction of the skin has been slowly taking place until ectropion
develops with perhaps contraction about the nostrils and mouth.
Eventually the naevi and warts become the seat of malignant degen-
eration. The ordinary freckle area is the one involved in this
disease.
Diagnosis
This affection could not be mistaken for another save perhaps in
its earliest stages.
Prognosis
The outlook is highly unfavorable. Exceptionally the period of
malignant degeneration may be so deferred that the patient dies
from some other disease but practically he is doomed to a lingering
death by marasmus. The individual lesions do not menace life as is
usually the case with epithelioma.
Treatment
This is entirely expectant and symptomatic.
Fig. 121. Model in St. Louis Hospital in Paris, No. 1464 {Baretta).
Quinquaud's case.
163
Keratosis Follicularis
Synonyms: Darier's disease, Psorospermosis
Plate 78, Fig. 122
This rare affection, first recognized by Barter in 1889, belongs
among the hypertrophies of the corneous layer and in its Inception
bears some resemblance to the lesions of lichen pilaris. As the
papules increase in size they are seen to contain a sort of sebaceous
core. At the outset they are discrete, but later they tend to form
patches composed of individual lesions which never exceed a large
pinliead in size. Beginning as a rule on the face and head or less
commonly on the hands, they develop very slowly, the lesions becom-
ing thicker and more confluent, while new localities are successively
attacked. Preferential regions are the sternum, loins and genito-
crural folds. Lesions may also occur on the extremities. With age
the sebaceous plugs may become horny. In some cases the accumu-
lations distend the follicles; and the resulting cavities may become
transformed to secreting ulcers.
Etiology
Darter believed it to be of parasitic origin, but this view has been
rendered imtenable. The affection is decidedly familial, although not
to the extent that some are, for the majority of cases are of solitary
incidence. It is not manifest at the early age of most of these presimi-
ably congenital affections, for in most cases it developed in adoles-
cence. Still a few began in infancy. Histologic studies appear to
show that we have to deal with errors in keratinization — a para-
keratosis. This error is probably a deep-seated one, dating back to
the developmental period, but perhaps not manifested ordinarily
until the later development of the pilosebaceous system. The affec-
tion remains throughout a very superficial one, the corium suffering
no notable changes.
Diagnosis
So few cases are known that not much can be said in regard to
possibilities of diagnostic confusion. In theory the latter might
164
Plate 78.
Fig. 122. Keratosis follicularis.
arise in reference to other forms of lichen before the disease had fully
developed, especially lichen pilaris. Again it possesses some resem-
blance to moUuscum contagiosum in that both affections have a
central, removable core. In fact, Darier believed the two to be
related.
Prognosis
There appears to be no tendencies to self-limitation or to spon-
taneous recovery. Tendency to degenerative change may exist, as
showTi by the development of epithelioma in one case, but this was
perhaps a mere coincidence. The general health does not become
impaired.
Treatment
The disease cannot be cured, for it is too deep-seated ; but it can
be benefited notably and by reason of its disagreeable character and
the disfigurement it requires vigorous management merely from the
cosmetic viewpoint. The management is similar to that of ichthyosis,
the concrements being cleared off with weak caustic alkalies and
salicylic acid applications. The X-rays may produce benefit and
there is some room for minor surgery in destroying the follicles.
Fig. 122. Model in Freiburg Clinic (Johnsen).
165
Elephantiasis Penis et Scroti
Plate 78, Fig. 123
The prepuce is highly disposed to edema, so that frequently recur-
ring inflammation appears to close up the lymphatics and cause a
stationary edema, -which in the course of time results in a thickening
of the skin and subcutaneous tissues. The constructive nature of this
process is apparent from the fact that in extreme cases aU subjacent
tissues participate. In such cases the integument may appear smooth
and intact or be the seat of ulcers and papillary outgrow'th.
It is common to consider this condition along "vs^ith elephantiasis
of the face, limbs, etc. In other words, there is often a single process
underlying all these forms. While in temperate zones vre cannot lay
bare any single factor, in elephantiasis in the tropics we find a special
cause in the filaria sanguinis which is able unaided to cause elephan-
tiasis of the penis and scrotum.
Diagnosis
The diagnosis of the condition presents no diflSeulties.
Prognosis
This varies according to the cause.
Treatment
TSTien produced by the filaria sanguinis the treatment is naturally
for that condition. In chronic cases satisfactory results sometimes
follow ablation of the hj'pertrophied tissue.
Fig. 123. Model in Cochin Hospital in Paris (Jumelin). Mauriac's case.
166
Plate 78.
Fig. 123. Elephantiasis penis et scroti.
Plate 79.
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Scleroderma
Plates 79 and 80, Figs. 124, 125, 126
This is probably a general affection, which is manifested chiefly in
the skin. The weight of evidence upholds the view that the earliest
manifestations are in the blood-vessels, and that an angioneurotic
element is also present. An initial stage of edematous infiltration is
soon followed by atrophy and shrinking of the skin, which as a result
becomes hidebound.
The affection manifests itself under three very different clinical
forms, which, while closely related and often occurring side by side,
are known by different names, and have been and still are, held by
some to be different affections. Occurring in small circumscribed
patches, the disease has always been known as morphea, and the
peculiar discolored appearance — yellowish, bluish, pinkish, etc. — with
its border of dilated blood-vessels, and its ultimate atrophy, causes it
to resemble greatly a patch of skin in lepra anesthetica, and it has
even been regarded as an anomalous form of that affection. How-
ever, there is no anesthesia, nor does morphea as a rule occur with
any definite relation to a sensory nerve. The lesions of morphea may
occur on the face, trunk or limbs. Diffuse scleroderma, or sclero-
derma in the narrower sense, may occur in a number of scattered
localities, or occupy a large portion of a limb, or may cover the
greater part of the surface, even to becoming universal, in which
case the patient becomes, as it were, mummified. "WTien the entire
face and neck are involved, the result is called the sclerodermatous
mask. The mucous membranes may be attacked. The third form of
the disease — sclerodactylia — attacks the digits, extending for some
distance centrally. This expression of the disease, especially in its
typical isolated form, is ranked with the acroneuroses, because the
trophic element is very pronounced. Not only do the fingers become
hidebound, but the bones and joints may undergo involutional
changes and ulcers may result.
The general form of the disease may run an acute course with
167
general sjanptoms resembling those of acute rheumatism. The
edematous stage is well marked in such cases, and often results
promptly in atrophy. As a rule, however, the disease begins insidi-
ously, is chronic when first noticed, and while edema is absent there
is considerable infiltration, which may not show atrophic changes for
a long period. The acute type of lesion not infrequently imdergoes
spontaneous involution. The tendency of the disease is to incapaci-
tate the subjacent organs. In the limbs the muscles atrophy from
pressure and disuse, and in some eases are directly attacked by the
disease. The joints are inmiobilized, the thorax impeded in its
movements, the emotions are no longer expressed, chewing and
swallowing are interfered with.
Etiology
Only in a few cases is there any conclusive relationship between
effects and causes, and such cases do not agree among themselves.
The apparent rheumatic nature of certain cases is of no help in
explaining the affection, and although a positive Wassermann reac-
tion is sometimes obtained, it is generally believed that the disease
is in no way related to sjT)hilis. Further speculation on the nature
of the affection is unprofitable.
Diagnosis
The resemblance of morphea and sclerodactylia to other affec-
tions, already cited, is evident ; but diffuse scleroderma can hardly be
confused "w^th any other condition save perhaps in its stage of
edema and infiltration, when it has been taken for myxedema.
Treatment
Owing to the fact that some cases improve and even recover
relatively without aid the benefits of treatment are naturally open to
doubt. Time is an important factor. The patient should be guarded
against cold, and residence in a warm climate is desirable. Internal
treatment is of little avail except when directed to improvement of
the general health. For this purpose ferruginous tonics, codliver oil,
strychnia, quinia, and occasionally arsenic are useful. Pilocarpin
properly supported b}' a stimulant has been recommended. Thyroid
extract has strong advocates as weU as disappointed experimenters.
In extensive cases it is at least worthy of trial. A few of my cases
were apparently slightly benefited by the use of potassium iodid.
Hehra has reported good results from the intramuscular injection
168
every second day of ten minims of a fifteen per cent, solution of
thiosinamin. The local treatment consists of massage and friction
with bland oils or ointments. Galvanism sometimes improves the
circulation and occasionally the X-rays may be of value.
Fig. 124. Model in Neisser's Clinic in Breslau (Kroener).
Fig. 125. Model in Lassar's Clinic in Berlin {Kasten).
Fig. 126. Model in Freiburg Clinic (Johnsen). The universal form of
scleroderma in a woman, aged forty-two years, who was suddenly at-
tacked with swellings about the ankles 7 months previously. For 6
months the skin of the whole body had been of boardlike hardness,
shiny and deeply pigmented, with scattered lighter spots and excoria-
tions here and there, especially about the anchylosed joints. The
patient became intensely emaciated, and died of an acute pleurisy
with effusion.
Atrophia Cutis Idiopathica
Plate 80, Fig. 127
Under this designation are at present comprised several clinical
conditions of wliich the most important are diffuse idiopathic cutane-
ous atrophy, dermatitis atrophicans, and acrodermatitis chronica
atrophicans {Herxheimer). In the two last named there is clear
evidence of an antecedent inflammatory stage; but in regard to the
so-caUed diffuse "idiopatluc" condition the evidence as to a prelim-
inary inflammatory stage is conflicting. This point is of vital sig-
nificance, for as a matter of fact the so-called "idiopathic" atrophy
is often secondary; while conversely, if the lesion is really primary,
it cannot be of the same nature as the secondary conditions, but
should be classed with congenital and hereditary hypoplasia of the
integimient.
In even the most modern literature there appears to be a hopeless
confusion between primary and secondary atrophy, and the impres-
sion appears to prevail that the same picture may be produced
whether the affection is dystrophic or secondary to an inflammatory
stage. The more one looks into the subject the more the designation
"idiopathic" seems to be unwarrantable. It can only imply that in
a person born with sound integument, and in the absence of any
exciting factors, atrophic conditions can develop.
In order to comprehend such a condition we may invoke, for
comparison, the disease scleroderma. Here we see many points of
resemblance with our affection. There is usually a primary stage,
which, however, may be latent. The localization is either diffuse or
circumscribed ; in the latter case especially involving the extremities
— in scleroderma the very fingers, but in the other form the hands
and forearms or legs. Scleroderma, itself a most mysterious affection
as far as its initial phases are concerned, causes, under typical condi-
tions, a most thorough atrophy of the skin.
Nevertheless, there is no close resemblance between the two con-
ditions. In so-called idiopathic atrophy there is no retraction present,
as in scleroderma. Instead of being hidebound, there is a laxness of
170
Plate 80.
Fig. 126. Scleroderma.
Fig. 127. Atrophia cutis idiopathica.
the skin, which is further suggestive of crumpled cigarette paper.
But cases of scleroderma have been reported which fulfil all these
conditions. Several authorities have recently expressed the opinion
that all cases of dermatitis atrophicans represent abortive sclero-
derma.
A survey of the sections on symptomatology, etiology and pathol-
ogy of this affection in the more recent text-books throws but little
light on our subject. The description applies equally to primary
and secondary affections.
In view of the anarchy which prevails in this field we can only
sum up our existing knowledge by stating that we cannot be clear as
to the primary or secondary nature of this disturbance ; that it affects
the middle-aged and especially the old by preference ; that irrespec-
tive of its origin it may progress and even involve the entire integu-
ment; and that there is no known plan of treatment capable of
modifying its course.
Fig. 127. Model in Neisser's Clinic in Breslau (Kroener).
171
Striae Distensae
Plate 81, Fig. 128
This is the condition originally described as "strise et maculae
atrophicas. " Maculae occur so frequently, however, that in some local-
ities the term is no longer employed. The lines have often been
termed lineae albicantes from their shining quality.
The phenomenon is normal in the gravida but is not of imiversal
occurrence. The same is true of rapidly acquired adiposity of the
abdomen and thighs. It is conmaonly held that the lesions appear
after delivery or rapid loss of flesh, but since a rupture of the corium
is believed to give rise to the striae, the latter might be in evidence
before the loss of flesh.
Observation shows that the lines are for the most part parallel,
their length is several inches and width about a quarter of an inch.
The color has been given as pure blue, livid or white, but these shades
are largely fortuitous and of no diagnostic significance. It is safe
to say that the lines are of a paler shade than the surrounding intact
skin.
Fig. 128. Model in Freiburg Clinic (Voffelbacher).
172
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Molluscum Contagiosum
Plate 82, Fig. 129
This mysterious contagious affection shows resemblances to
numerous widely different dermatoses. It has been classed as a form
of acne, sebaceous tumor and neoplasm ; and one of its oldest names
(acne varioliformis) is based on its resemblance to the umbilicated
vesicles of smallpox. For some years it was believed to be due to
certain parasites — coccidia^ — but this view has almost been aban-
doned. Under the microscope it represents a benign form of epi-
thelioma, and presents some superficial clinical resemblance to
multiple, benign cystic epithelioma. The lesions resemble cysts, in
having fluid or solid contents, which may be squeezed out of a central
opening. They leave no traces, not even in case of suppuration,
which sometimes results.
The lesions vary from pinhead to pea size, are multiple, and are
either pearly white or pinli. They are discrete, but may form small
groups, and while they may occur exceptionally in any area of integu-
ment, are usually found on the face or genitals. They are firm to the
touch, of globular outline, with slightly flattened summit, and natu-
rally sessile, becoming pedunculated in some cases at a later period.
Atypical varieties have been described.
Etiology
Not only can no parasitic cause be found for this affection, but
even the conditions under which it can be propagated are barely
known. Like impetigo contagiosa, it tends to prevail among the
children of the poor and in institutions. There is a small per cent.
of cases in which direct inoculation is evident, and it may also be
inoculated experimentally. Despite its occurrence on the genitals,
there is no evidence of venereal transmission. There is quite a con-
sensus of opinion that it follows visits to bathing establishments.
The affection was long believed to involve primarily the sebaceous
glands, which if true would make the matter of contagion more
173
intelligible. As a matter of fact, however, the disease begins in the
rete and has no connection with glands or follicles. The central
opening, which originally suggested the sebaceous gland theory, is
part of the evolution of the tumor.
Diagnosis
The peculiar formations mth their central depressions and duct-
like orifices, when typical, can hardly be mistaken for the lesions of
any other affection. Atypical lesions about the eyes might be con-
fused with milia or warts. Beginning lesions present some analogy
to acne papules.
Treatment
Many cases terminate in spontaneous recovery in a few weeks or
few months, but the contagious nature makes vigorous treatment
necessary. Parasiticides, such as sulphur or mercurials in ointment
form, rubbed in forcibly, are curative, and are usually prescribed if
many lesions are present. The treatment for individual lesions is
incision or expression, followed by cauterizing "with pure carbolic
acid.
Fig. 129. Model in Lesser's Clinic in Berlin {Kolhow).
174
Keloid
Plate 82, Fig. 130
This term is applied to a scar-like new-growth of the skin. Its
resemblance to a scar is by no means accidental, for in the majority
of cases it develops in a recent cicatrix, and in its mildest form is
nothing but a redundant scar. In a degree one remove higher it
appears at first las a redundant scar, but grows beyond the original
scar limits; and in the highest degrees it appears to develop spon-
taneously in sound skin. This, however, is very questionable, for
in these so-called spontaneous or idiopathic cases the skin has almost
always been subjected to friction and intermittent pressure ; and when
we bear in mind that about half of these idiopathic cases occur over
the sternum and have a history of mechanical irritation, the inference
is that an initial abrasion or some other slight traumatism may have
furnished the impulse for the new-growth. And we know, besides,
that scar keloid so-called can follow a very small lesion of the skin.
There is no doubt that a marked predisposition to these growths
exists, but beyond the fact that negroes show a distinct tendency in
this direction, we cannot formulate it.
A keloid tumor, however produced, shows a marked tendency on
the part of the fibroplastic tissue of which it is constituted to retract,
like the ordinary scars of burns. As a result the growth has numer-
ous processes resembling claws, whence the name. The superficial
processes or roots of a keloid are roughly analogous to the so-called
roots of a cancer of the breast which are also produced by the retrac-
tion of the fibroplastic tissue; and keloids, like cancers, have a
notable tendency to recurrence after removal, although they are not
malignant.
Diagnosis
A keloid can hardly be mistaken for any other affection because
its appearance must suggest a scar.
176
Treatment
This has always been far from satisfactory. Excision is always
contraindicated. Palliative treatment (anodynes) is necessary at
times when the growths are painful. A combination of fibrolysin
injections, linear scarification and electrolysis may prove successful
in some cases. Improvement often follows the use of the X-rays.
Naturally the treatment is in part comprised under that of disfigur-
ing, incapacitating and painful scars such as follow extensive
injuries.
Fig. 130. Model in Kaposi's Clinic in Vienna (Henning).
176
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Xanthoma Tuberosum Multiplex
Plate 83. Figs. 131 and 132
In this type of disease nodules occur, as the name implies ; but flat
patches sometimes coexist. This form is only exceptionally seen about
the eyelids, but occurs disseminated in various localities, so that it is
termed xanthoma tuberosum multiplex. Favorite localities are the
hands, knees, elbows, buttocks and feet. The individual nodes are
about the size of a pea and as a riTle they are closely aggregated. A
puzzling feature is the frequent association of jaundice, although the
xanthomatous nodes and plaques in no wise owe their yellow color
to bile.
The coalescence of nodules may be so extreme that true tumors
result. Otherwise the condition is simply very slowly progressive,
with little or no tendency to disappear by involution nor to de-
generate.
Etiologi/
Zanthoma has been recognized as a- familial affection, cases having
occurred in at least four generations. The lesions are known to de-
velop in some of the internal organs. Little or nothing is knoTvn of
the determining causes. The neoplastic tissues appear to contain a
special kind of fat to which they owe their yellow color.
Diagnosis
Xanthoma tuberosum multiplex, when it occurs away from the eye-
lids and vicinity, is hardly to be confused with any other malady. It
is stated that urticaria pigmentosa has been known to simulate it. In
theory it might be confounded with the so-called xanthoma of dia-
betics. This, however, represents a fatty degeneration of disseminated
inflammatory lesions. Occurring on or about the eyelids, it might of
course be confused with xanthoma planum ; but xanthoma tuberosum,
while it may occur on the lids in a flattened form, will always be
accompanied by the tuberous lesions elsewhere on the body.
177
As in the case of neoplasms of any sort, extirpation is the only
treatment. The affection is weU adapted to curettage, and if the
lesions are small or few in number, electrolysis or the use of moder-
ately strong caustic solutions may be sufficient. If there is fear of
disfiguring scars a strong salicylic acid plaster or coUodium solution
applied repeatedly may cause the disappearance of the lesions. For
large plaques on the elbows and knees the X-rays may be used.
Fig. 131. Model in St. Louis Hospital in Paris, No. 655 (Baretta).
Besnier's case.
Fig. 132. Model in St. Louis Hospital in Paris (Baretta).
Du Castel's case.
178
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Xanthoma Palpebrarum
Plate 84, Fig. 133
This affection seemingly has no connection with xanthoma tuber-
osum multiplex. As the name implies, it is peculiar to the eyelids.
It is roughly symmetrical and both the upper and lower lids may be
affected. The lesions are of a chamois color and of oval form, from
one-eighth to one-half of an inch in their long diameter. Adjacent
lesions may coalesce and form irregular bands and patches. The
affection is seen most frequently in women, particularly those show-
ing dark pigmented rings around the eyes. Although rare in men
it is occasionally encountered.
Etiologj/
But little can be said regarding the cause of the affection aside
from the fact that it is known to possess a fairly definite hereditary
tendency.
Diagnosis
This affection is frequently confused with typical xanthoma, espe-
cially when the latter is seated in the lids, in which case it assumes
a similar flattened type. The absence of lesions on the body, however,
should prevent this diagnostic error.
Treatment
The growths may be destroyed by electrolysis, refrigeration, or
by chemical caustics. Touching the lesions with pure nitric acid is a
simple but effective treatment.
Fig. 183. Model in Lesser's Clinic in Berlin (Kolbow).
179
Atheroma Multiplex
Plate 84, Fig. 134
Wens, or sebaceous cysts, despite the above designation, are nsn-
ally single and seldom niunerous. Since the contents of these cysts
is ordinary sebaceous matter, the first impression is naturally that we
have to deal with ordinary retention cysts from occlusion of the
ducts. But not only are the latter often patent, so that the contents
are easUy pressed out, but mere stoppage of a duct is evidently
insufficient in itself to cause a wen.
Wens may be of any size up to that of an orange, and after
reaching a certain size — for example, that of a bean or an almond — ■
undergo no further change unless they inflame. Their favorite
locality is the scalp and adjacent parts of the face and neck, and the
back, but they may occur in any locality whatever. In certain locali-
ties they show peculiarities which cause them to pass for special
affections, as the chalazion of the eyelids, which are connected with
the Meibomian follicles. They often occur in the scrotum, and some-
times the labia majora are affected. In wens with patent duct,
cutaneous horns are occasionally produced.
Wens naturally lie beneath the skin, which moves freely over
them ; and if they do not inflame the contents gradually harden. It is
asserted that if there is no patent outlet the growths become more
bulging. A low grade of inflammation causes the cyst-wall to adhere
to the skin, which itself may inflame, become thin and ulcerate. An
ulcerated wen may show papillomatous outgrowths, and may even
become the seat of an epithelioma.
Diagnosis
Without a history of the case, a wen might readily suggest a sub-
cutaneous granuloma, either s)T)hilitic or tuberculous, especially if
no opening is to be seen. The presence of the latter, and the escape
of sebaceous matter therefrom under pressure, is characteristic of
180
•wens. In dubious eases a needle puncture might be made, but the
indications for extirpation are so marked that refinements of diag-
nosis are hardly called for.
Treatment
This consists in incising the skin and shelling out the cyst, save in
small, beginning wens, which may be simply punctured, evacuated
and cauterized. When adherent to the skin, careful dissection is
required.
Fig. 184. Model in Neisser's Clinic in Breslau (Kroener).
181
Lupus Erythematosus
Plate 85, Figs. 135 and 136; Plate 86, Figs. 137 and 138;
Plate 87, Fig. 139
This affection comprises two types of disease, which differ so
notably as ahnost to constitute clinically separate affections. Never-
theless, they show transitions and the ability to pass from one phase
into the other.
The first type to be described has a decidedly rashlike character,
and is kno^-n as the exanthematous or disseminated. It varies greatly
in degree and severity, and in its mild forms seems to be regarded by
most authors as belonging to the localized, circumscribed type. In
this form a few scattered lesions may appear on the face, and perhaps
also on the hands and arms. These lesions are mere erythematous
spots, varying much in size, but seldom larger than a bean. They
may be very few in number, with a tendency to appear on or about
the nose, in which locality they may simulate seborrhoic dermatitis or
acne rosacea. On the other hand, the face, hands and forearms may
be quite tliickly sprinkled with lesions, so that they bear considerable
resemblance to erythema multiforme. It is difficult to associate such
insignificant-looking lesions with the word lupus. Like any other
exanthem, these spots may disappear spontaneously, and often yield
readily to local treatment. As a rule, however, they tend to reappear.
Wlien they vanish they may leave behind superficial temporary white
scars. Some spots appear to sear in the centre only. Subsequent
lesions, when they appear, no longer show any tendency to recovery
and become ordinary circumscribed chronic lesions which make up
most of the cases of this affection.
There is also an infrequent, much more severe and generalized
form of exanthematous lupus which may involve a much greater area,
and be attended with constitutional SAonptoms. This type is often
fatal. Most of the cases are associated with general tuberculosis,
others with nephritis or syphilis. This type has been known to
develop in subjects already affected with the ordinary chronic
localized form. The eruption may itch notably, and show much poly-
182
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morphism. It frequently resembles a generalized erythema multi-
forme, to such a degree, in fact, that no distinction can at first be
made.
However interesting and striking these cases may be, lupus erythe-
matosus is for all practical purposes a very different affection — an
eminently chronic, localized process, confined to certain areas. These
comprise the nose and adjacent parts of the cheeks, the ears and
region behind them, the scalp, fingers and hands, and occasionally the
toes. The same subject does not as a rule present lesions on both the
head and extremities, so that clinically two different local types may
be represented. Exceptionally other localities near the favorite ones
may be involved, as the eyelids and the red border of the lips. The
most striking and characteristic location is the so-called butterfly
area, in which one large patch occupies the nose and entire infra-
orbital regions ; and generally speaking, symmetry is highly typical
of this form of disease. Thus, if one ear is affected the other will
be. If there is a patch behind one ear, there will be a corresponding
one on the opposite side. If a large number of cases are analyzed, it
will be found that the majority follow a single local type, the lesions
being confined entirely to the nose, cheeks and lobules of the ears.
These lesions may be perfectly flat or even slightly below the
level of the skin, but as a rule more or less infiltration is present, so
that they are elevated above the skin. These variations are due to
the fact that in chronic erythematous lupus there is always a new
formation of small cells which have some tendency to undergo atro-
phy. We may therefore see either hyperplastic or atrophic change
and sometimes both side by side. This infiltration is able to destroy
the integrity of the skin and produce scarlike tissue without previous
ulceration. The resulting lesion is not a true scar and there is little
or no retraction, but it imposes itself as scar tissue. The infiltrated
skin has a bright red color, and does not pale on pressure ; this is true
also of exanthematous lupus. Thick, closely adherent scales may be
present on the patches, and the borders are sharply outlined. Excep-
tionally, even after considerable infiltration, the skin may remain
intact, so that after the retrograde changes it appears normal. On
the fingers or elsewhere in the chilblain area the lesions may be
livid instead of red. Exceptionally, a patch may appear edematous.
Patches in the hairy scalp cause localized permanent alopecia.
Etiology
But little is knowm of the intimate nature of the malady. It has
often been claimed that the disease is in some manner dependent upon
183
tuberculosis, but proof of this fails. Bacilli do not appear in the
lesions, and to claim that circulating toxins are responsible leads to
nothing. Its choice of locality may be determined by the fact that
these areas are naturally hyperemic or congested, and it sometimes
seems to develop in previous affections in these localities.
Diagnosis
Beginning lupus about the nose often suggests seborrhoic derma-
titis or rosacea, and as the disease may begin in these forms, it may
be impossible to give a positive opinion for a time. In lupus the
sebaceous follicles are often very prominent. The patches of exan-
thematous lupus may simulate eczema, as they may itch and show
small papules and vesicles. The one disease which offers the closest
resemblance is lupus vulgaris, and in a small percentage of cases
diagnosis becomes so difficult that a hybrid form has been spoken
of. Otherwise, the resemblance is chiefly illusional, for in the great
majority of cases the affections present little in common.
Prognosis
In a case with some tendency to spontaneous improvement, vigor-
ous treatment may bring about complete recovery; but in the great
majority of cases it is a question of improvement only.
Treatment
Internal treatment should be directed first of all to the correction
of any defect which may be found in the patient 's general health.
A great many remedies have been recommended on account of
their supposedly specific action upon the disease itself or upon the
toxemia causing it or for their power of contracting the dilated blood-
vessels. The most important of these are arsenic, the salicylates,
carbonate of ammonia, quinia, the iodides and ichthyol. The results
from all, however, are usually disappointing.
In the hyperemic-spreading cases iodine in the form of iodoform
is frequently of value. The spreading is checked, the acute in-
flammatory condition subsides and occasionally a cure is effected.
Whitelwuse recommends that it be given in one-grain pills, coated
with keratin or salol to prevent solution in the stomach. The dose
is one pill three times a day after meals, gradually increased to the
limit of tolerance, which is usually eight or nine pills a day. Its
effect upon the digestive tract and upon the kidneys must be care-
fully watched, and its use should be continued for several months.
Bulkley recommends phosphorus in the form of Thompson's solution
in increasing doses pushed to tolerance.
181
For external use the number of remedies is even larger than for
internal, and in most cases their action is quite as disappointing.
The choice of the remedies will depend upon the type of the disease
and the character of the individual skin.
In the acute inflammatory or vascular type only soothing applica-
tions are indicated, such as a calamine and zinc or a zinc and
magnesia lotion and boric acid or mild ichthyol ointments.
As the acute process subsides, more active remedies can be used,
such as painting the surface with liquor potassse, allowing it to dry,
and then covering it with collodion. The collodion peels off after
four or five days and the process is repeated.
Lotio alba gradually increased in strength from 3i each of zinc
sulphate and potassium sulphuret in §iv of water to 3vi of each, is
often valuable in this stage. It is to be applied from two to four
times a day.
Resorcin, from five to fifty per cent, in alcohol, is also useful.
Green soap applied either as a plaster or in the form of the
tincture removes the scales and may stimulate a healing process.
The best results from all of the above are seen in the semiacute
eases which show only slight infiltration : in the fixed chronic cases
they are of but little use, and more radical methods must be employed.
The action of all active remedies must be watched closely, and when-
ever an inflammation is excited they must be discontinued and one of
the soothing applications used until this subsides.
In the chronic fixed cases one of the best remedies is equal parts
of tincture of iodine and glacial acetic acid applied two to four times
a day. The amount of iodine can be increased as the skin becomes
tolerant.
Hollander recommends that quinine in increasing doses be used
in conjunction with iodine externally.
Curettage is beneficial, especially ia those cases with excessive
scaling and thickening.
The remedy, however, which offers the best results is carbon
dioxide snow. Its use should be restricted to those cases where the
process has become stationary; or to lesions which have persisted
for several months and show no tendency to spread.
There are several ingenious mechanical devices for making the
CO2 crayon, and while they are convenient, a piece of blotting-paper
will answer the purpose quite as well. The blotting-paper is rolled
to form a cylinder about three or four inches long with a diameter
to fit snugly over the outlet of the tank containing the liquid COj.
185
This is firmly bandaged on the outlet, the tank inverted and the valve
opened gradually allowing the liquid CO2 to run out. With a little
practice a firm, hard crayon is obtained, which can be trimmed with a
knife to the desired size.
The reaction f oUowiug the use of the snow is often quite severe,
and it is not advisable to use it over a surface larger than one or
one and a half square inches at one treatment. Over the bony prom-
inences, and where there is little subcutaneous tissue, as the nose, it
must be used very carefully to avoid too much destruction of tissue
and sloughing. It should not be used at all on the ears. It should be
applied first at the edges of the patch to be treated, and at least one-
eighth of an inch of normal skin should be Included in the process.
The amount of pressure and the duration of its application vary in
individual eases, and in the beginning it is advisable to limit both.
Twenty seconds, with moderately firm pressure, is safe, and from this
one can estimate what will be necessary later. The crust which
forms usually separates in from ten to fifteen days.
Figs. 135, 136 and 138. Models in Neisser's Clinic in Breslau (Kroener).
Fig. 137. Model in St. Louis Hospital in Paris, No. 1437 (Baretta). Vi-
dal's case. — Symmetrical lupus erythematosus of the hands of 2 years'
standing. The face was likewise affected.
Fig. 139. Model in Freiburg Clinic (Johnsen). The superficial invasion of
the skin of the cheeks permits the recognition of the existence of
numerous small circular lesions, especially in the marginal portions of
the disease. Under internal treatment with quinine and painting with
iodine the affection was soon reduced to minimal proportions.
186
Plate 87.
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Lupus Pernio
Sjnonym: Chilblain lupus
Plate 87, Fig. 140
It has already been stated that lupus erythematosus may appear
only upon the hands, and that when confined to the fingers and toes
it may occupy the chilblain area and possess a resemblance to chil-
blains otherwise. Most authors make a special type of disease of
chilblain lupus, asserting it to be a different affection from lupus
erythematosus. They point to the fact that similar congested, livid
areas appear in other chilblain localities, as the nose and ears ; that
the subjects are anemic with poor circulations, and are subject to
chilblains, and that the affection itself may begin upon this founda-
tion. In this form of lupus the thick adherent scales, the dilated and
obstructed sebaceous ducts, and the sharply outlined, elevated border
are absent. The affection may recover without scar-formation, even
after years of persistence. The same secondary lesions develop as in
severe cases of common chilblains. The only distinction between the
two is the principal fact that chilblain lupus is present the year
around, once it has begun. But if the face and ears are involved
together, as is often the case, the condition could not, of course, be
mistaken for the effects of the weather, even in winter.
Treatment
The management is essentially that of severe chilblains, viz.,
attempts to improve the circulation by internal and local treatment.
Severe local measures are contraindicated.
Fig. 140. Model in St. Louis Hospital in Paris, No. 16D4 (Baretta).
Terineson's case.
187
Lupus Vulgaris
Plates 88 to 94, Figs. 141 to 152
This form of tuberculosis of the skin is believed to differ from
other species in being caused by the action of a limited number of
germs of low virulence upon tissues which may have a certain predis-
position or immunity. They resemble the so-called tertiary lesions
of tuberculous infection, and also bear a close resemblance to the
tertiary syphilitic lesions of the corixmi. On the other hand, it is
believed that they originate from inoculation in or near the seat of
the lesions, and that the low degree of virulence may come about from
the fact that the subject has become partly immunized by the dis-
ease. Transitions occur between lupus vulgaris and ordinary inocu-
lation tuberculosis (where a predisposition is not in question), and
typical lupus itself plainly results from inoculation in certain cases.
A special disposition to the disease is furnished by certain localities,
as portions of the face and hands; these agree roughly with the
areas of choice in circumscribed erjrthematous lupus, and to this
parallel is due the fact that the latter affection, although not techni-
cally destructive enough to merit a designation like lupus, has come
do^\Ti to us as a process cognate with true lupus.
The affection begins as a characteristic nodule occupying the
thickness of the true skin. These are minute and readUy coalesce to
form disease foci. When one of the latter has become conspicuous
it is seen to have a peculiar hue, often likened to those of apple-sauce
or apple-jelly. It becomes less marked on pressure, but still has a
yellowish-bro'wn color. This corresponds to an infiltration of
granulomatous tissue, Avhich soon softens, so that a fine probe readily
enters it. This new tissue has already destroyed the thickness of the
skin, yet the lesions may long remain at an apparent standstill before
any further changes occur. New lesions tend to appear close by,
however, so that in time a patch of considerable size has been formed.
188
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These patches are usually a dull or bright red. In time the older
lesions begin to show regressive changes. The natural tendency is
to very slow absorption, leading to atrophy of the derma. During
this process a peculiar anomaly of desquamation is usually present.
Large masses of scales become partly loosened, but remain adherent,
so that when forcibly detached hemorrhage results. At the comple-
tion of the atrophy this scaling ceases. The other termination is by
ulceration, and this may be due largely to mixed infection from
without. The ulcers discharge pus, which quickly dries into dark-
colored crusts. In certain cases exuberant granulations form. An
old patch of lupus which has slowly formed during years presents a
characteristic appearance ; several or all of the changes just described
may be present at the same time. The new lesions naturally appear
on the margin of the patch, sometimes forming a serpiginous border
so characteristic of parasitic disease in general.
Despite the areas of preference, the disease readily occurs on the
limbs, buttocks, and in fact in almost any locality, and it is not
uncommon to see it develop simultaneously in widely separated
localities. It attacks any of the superficial mucosae, and may be
primary here as well as secondary. The great disfigurement which
it is capable of causing is not due to any penetrating power or ability,
like cancer, to attack all structures, but to cicatricial or atrophic
retraction about delicate orifices, and to interference with the nutri-
tion of the more fragile bones and cartilages. Hence the sinking in
of the nose. On the other hand, ordinary acute tuberculosis caused
by large numbers of virulent bacilli is able to attack any of the
tissues and produce destruction in a short interval. The area
involved, however, is fortunately small, so that clinically there is no
resemblance to lupus. There is, however, a process described by some
authors as acute lupus, in which there are evidences of active inflam-
mation and a tendency to rapid disintegration.
The affection, in the majority of cases, begins in childhood, and
since it is quite compatible with a fair state of nutrition and does not
kill either directly or indirectly, and, moreover, since it tends to
progress or at least to remain stationary and is not especially
amenable to treatment, the patient is almost sure to suffer with it
during the entire life, be this long or short. Since practically its
progress is very slow, the phenomena vary essentially with the
duration. The older the case the greater the amount of atrophic and
cicatricial tissue. The intensity of the disease at a given period is
shown by the extent of new patches of disease. A time may come
189
when there are no longer any fresh nodules, the lesions then being
wholly made up of the secondary changes. Although the disease may
be extinct, or at least latent, the slow retraction may still be in evi-
dence. Thus the entire face may be transformed to atrophic and
cicatrized skin, and the apertures of the nostrils, eyelids, and even the
mouth may be narrowed to an extreme degree, the nasal prominence
being at the same time affected. Yet with all this local mischief the
general health may remain excellent. The fingers and toes may also
undergo analogous changes.
Typical lupus is but slightly raised above the skin level during
the period of infiltration, and the exuberant granulations which may
form on ulcerated surfaces have been mentioned. But aside from this
there is a distinct tendency in certain individuals to proliferation of
the various tissues which make up the corium. There results, then,
clinically, such varieties as lupus hj^jertrophicus, lupus papilloma-
tosus, and lupus verrucosus. The same occasional tendencies are seen
in other destructive diseases of the skin, and are doubtless due to
individual peculiarities, although lupus verrucosus occurring on the
fingers or hands is seen in butchers and dissectors ■without special
predisposition, and seems to stand midway between true lupus and
actual inoculation tuberculosis. The typical lupus nodule does not
occur here, which has led to the rejection by many of this affection
as a form of true lupus.
Lupus is also atypical in the lesions known as scrofuloderma,
which often stand in actual relationship to scrofulous glands and
acute scrofula in various organs. Some of these lesions represent
small cold abscesses of the corium, and in general there is here a
transition between true lupus and the more acute forms of tuber-
culosis.
Etiology
Much has been said under this head, and it only remains to discuss
the probable relationship between true lupus and general or pul-
monary tuberculosis. The evidence points to the fact that in lupus,
as in certain so-called scrofulous affections, the patient seems to have
become partly immunized to fatal tuberculosis. Nevertheless, in a
certain per cent, of cases there is no immunity, and the patients perish
of pulmonary tuberculosis. There is no doubt whatever that lupus
patients come of tuberculous stock in a preponderating proportion.
190
Plate 90.
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Plate 91.
Fig. 147. Lupus vulgaris serpiginosus.
Plate 92.
Fig. 148. Lupus vulgaris (elephantiasis
consecutiva).
Fig. 149. Lupus vulgaris (mutilatio).
Plate 93.
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Diagnosis
Typical lupus may easily be recognized from the chp^racters al-
ready given. Atypical forms may so mimic other destructive affec-
tions, such as lupus erythematosus, tertiary syphilis, rodent ulcer,
epithelioma, tubercular leprosy, blastomycosis, etc., that diagnosis
for the time may be quite impossible, or at least extremely difficult.
The von Pirquet test and the Wassermann reaction are often of great
help in differentiating lupus from syphilis. Certain fungi (blasto-
myces, etc.) may produce lesions accurately simulating lupus of the
face and extremities. This confusion is more likely to occur in tropi-
cal countries. The only way to solve these puzzles is by microscopic
studies, which may reveal the presence of blastomyces. Leprosy,
when it first invades the nasal chambers and septum, readily simu-
lates lupus, or, perhaps better, tuberculosis. The reason for the
reciprocal simulation of granulomatous affections is due to the fact
that these represent a group disease, and behave more or less alike.
A rodent ulcer which heals partly while still progressing resembles a
small isolated patch of lupus at times, and it is now known that
lupus can begin in the elderly. Again, epithelioma readily develops
in an ulcerated lupus, and in such a case has to be differentiated from
lupus with overgrowth of tissue. An ulcerated lupus may also pass
directly into cancerous ulcer without any additional infiltration.
Treatment
The Finsen light treatment is in some respects a specific for
lupus, the X-rays, however, constitute a more available resource,
having nearly as great efficacy. The large number of exposures
necessary and the resulting tediousness, however, make some more
rapid method in demand for all save those who wdsh above all for
cosmetic results. One plan of treatment which may be summed up
as asepsis and antisepsis seeks to minimize the disease by excluding
septic infection. This may be carried out in a variety of ways. The
lupus nodules will then pursue an uncomplicated course. The anti-
septics most in use are pyrogallic and salicylic acids. This treatment
can, of course, be pursued with lupus of any stage or variety; and
it seems to be preferred by many over active destructive measures.
Destructive cautery, curettage, and excision seem to be indicated less
and less since a combination of X-rays with antiseptics have come
into vogue. The latter does far more, perhaps, than merely prevent
secondary infection. Pyrogallic acid has considerable power as a
mild destructive caustic. If the superficial tissues are first softened
191
by salicylic acid, pyrogallic acid is able to penetrate into the tissues
and perhaps to destroy the tubercle bacillus and arrest the small cell
infiltration. It thus works hand in hand with the bactericidal action
of the rays.
Figs. 141, 142 and 150. Models in Freiburg Clinic {Johmen).
Figs. 143 and 147. Models in Neisser's Clinic in Breslau {Kroener),
Fig. 144. Model in St. Louis Hospital in Paris, No. 1059 (Baretta).
Guibout's case.
Fig. 145. Model in St. Louis Hospital in Paris (Baretta). Besnier's case.
Male, aged fifty-one; disease of 22 years' standing, only slightly
treated, especially never with thermo-cautery.
Fig. 146. Model in Neisser's Clinic in Breslau {Kroener). Patient is
still living.
Figs. 148, 149 and 151. Models in Neisser's Clinic in Breslau {Kroener).
Fig. 152. Model in Freiburg Clinic (Johruen).
198
Plate 94.
Fig. 152. Lupus vulgaris mucosae oris.
Fig. 153. Verruca necrogenica.
Verruca Necrogenica
Synonym: Post-mortem wart
Plate 94, Fig. 153
Under lupus vulgaris mention was made of a form, lupus verru-
cosus, described by authors, which in some instances appeared to
result from direct inoculation with tuberculous matter. Such lesions,
while sharing some of the features of conunon lupus, are usually
held to be more allied to ordinary inoculation tuberculosis, about to
be described. In these cases there is no predisposition required.
Butchers and dissectors alike may be professionally inoculated, the
accident occurring as a rule over a knuckle. The lesions must not
be confounded with dissection pustules which are due to ordinary
pyogenic cocci. The lesion develops slowly, resembling a wart in its
evolution. There is an overgrowth of papillsc, a slight secretion of
pus and the formation of a crust, which forms again whenever de-
tached. A considerable size may be attained — an inch in diameter;
and as the lesion increases there is some disposition to heal in the
centre. That such a condition may pass by transitions into lupus
verrucosus is manifest. Since no predisposition or special immunity
exists, the natural defensive forces are operative and the lesion either
heals of itself in time or in rare cases infects the organism with
acute general tuberculosis. Fatal cases are very rare, however, and
the more severe cases are probably due to mixed infection, \\ith
lymphangitis and general toxemia.
A condition known as tuberculosis verrucosa cutis, which occurs
on the hands and feet and may be very extensive, occupying an entire
foot, stands in some common relationship ynth. lupus verrucosus and
verruca necrogenica.
Diagnosis
Post-mortem wart must be differentiated from ordinary warts,
193
which often grow rapidly after local irritation, and post-mortem
pustules. A microscopic examination should decide the matter.
Treatment
It should be easy to destroy these growths with the thermocautery.
Cases may arise in which it would be more expedient to use the
X-rays.
Fig. 153. Model in Freiburg Clinic (Jacobi),
194
Plate 95.
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Plate 95, Fig. 154
The tuberculous ulcer, or as it is more commonly called rhagade
of the tongue because of the greater frequency and importance of the
fissured form, is in the great majority of cases situated on the sides
or dorsum of the organ. The first stage is the deposition of tubercles
which sooner or later break down. The ulcer, when one forms, seldom
exceeds the size of a bean. It is of variable depth and presents a
grayish-green floor. Sometimes there is an attempt to granulate,
notably after treatment. The edge is usually undermined and some-
what indurated. The rhagade is more common and is narrow and
deep in comparison with the ulcer. It may appear shallow until the
edges are separated, may even appear as a mere furrow. It may
persist for a long time and eventually take on more of an ulcer
form. Meanwhile new tubercles may form and ulcerate. The slow
course sometimes pursued suggests an analogy with lupus. Tuber-
culous lesions of the tongue are usually secondary, but exceptionally
they seem to be primary and as such have a relatively good prognosis.
Diagnosis
This is often made with great difficulty. Syphilis and cancer are
the principal diseases to be excluded.
Treatment
This in primary tuberculous ulcer should be radical. In the
milder cases, if the diagnosis is assured, a wedge-shaped section
should be removed. If the area involved is considerable the paquelin
or galvano-cautery, the curette, lactic acid, iodoform, and creosote
shoTild be our chief resources.
Fig. 164. Model in St. Louis Hospital in Paris, No. 1768 (Baretta).
Tenneson's case
195
Tuberculosis Nasi
Plate 95, Fig. 155
Two lesions aside from lupus may occur about the nostrUs from
tuberculosis. One is the tuberculous tumor, or gunama, which may
be primary, and forms just within the nostrils, usually in the septum.
This may soften and ulcerate. The other lesion formed by the
coalescence of miliary tubercles to form a typical tuberculous ulcer
is seen as a rule only in people with advanced phthisis and is ex-
tremely rare. There is reason to believe, however, that it may occur
in latent pulmonary tuberculosis. The lesion resembles in every way
the types seen in other localities.
Fig. 155. Model in St. Louis Hospital in Paris, No. 2236 (Baretta).
Hallopeau's case.
196
Plate 96.
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Lichen Scrofulosorum
Plate 96, Fig. 156
This affection is not conspicuous and gives rise to but little discom-
fort. The primary lesion is a miliary papule, these being closely
grouped. They are red only at the outset. Sooner or later they
become decolorized and may be either yellowish or skin-colored, in
the latter case resembling goose-flesh. Sometimes they are tawny or
brownish, as if from pigmentation. The closely set papules are each
surmounted by a little scaliness and when involution begins the more
centrally seated papules go first, and cireinate lesions are often
formed. Sometimes minute hemorrhages occur giving the lesions a
livid hue. In certain cases the follicles seem to be implicated more
directly and the papules then contain a sebaceous plug.
The patients are usually accidentally found to have this peculiar
eruption on the trunk, usually about midway. The subjects are chil-
dren or young adults of scrofulous habit. Of this affection it may
be said that aside from the lesions themselves there are no symptoms.
In rare cases similar lesions are seen on the limbs.
Etiology
The affection is believed to be a tuberculide, and in a few cases
bacilli have actually been found. It stops short of being an active
tuberculosis, although histologically it seems to consist of a tuber-
cidous process about the hair-follicles. From the results of experi-
ments it is possible that the process is due to the action of the toxins
alone, although the rationale is obscure. It is known that scrofulous
lesions of whatever kind are much less virulent than tuberculous ones,
and that the subjects appear to have become immunized in a measure.
Diagnosis
There are a number of affections which produce miliary papules,
but the seat, grouping, color and collateral evidences of scrofula
should make the diagnosis. Other affections are keratosis pilaris,
197
papular eczema, lichen urticatus and syphilis, and in none of these,
save perhaps when the limbs are involved, should there be any
possibility of confusion.
Prognosis and Treatment
With no tendency to absolute recovery, since new lesions may
replace old ones, the affection is nevertheless readily controlled by
antiscrofulous measures — chiefly cod-liver oil internally and exter-
nally.
Fig. 156. Model in Freiburg Clinic (Johnsen),
198
Erythema Induratum Scrofulosorum
Synonym: Bazin's disease
Plate 96, Fig. 157
This affection bears considerable resemblance to erythema nodo-
sum, being seated like the latter chiefly in the legs; it is, however,
always a chronic condition, as a result of the continual appearance
of new lesions. The lesions may be palpated beneath the skin before
they become visible. They are then no larger than peas, and increase
very slowly in size, nearly that of an English walnut. The skin over
them becomes livid. They may in time undergo spontaneous involu-
tion or soften and ulcerate. Under the latter condition they naturally
resemble syphilitic gummata. There is no suppuration, and the
process is really a central necrosis, the resulting loss of substance
being small at first. Eventually the entire nodule sloughs and this
may even occur at the outset. There are several other clinical forms,
as for example when a large node undergoes necrosis at two points,
or two closely placed nodules each ulcerate.
The patients are almost always girls and women in poor health
and circumstances and the lesions are largely peculiar to the legs,
especially the lower portion. In a case of some duration various
sized nodules and ulcers are seated side by side and between the
lesions the skin appears purplish. Scars may be present and small
nodules may be felt under the skin.
Etiologi/
This affection is believed to be related to tuberculosis, but the
connection is hard to trace as the bacilli have never been found. The
presumption is based on histologic and inoculation tests ; also on the
scrofulous habit of the patients.
Diagnosis
The resemblance to multiple syphilitic gummata is at times start-
ling, but the course is more indolent, and late syphilis is not a
199
symmetrical disease. Erythema nodosum is at the begimiing an
acute disease while the other is sluggish; the former, while it may
become chronic, never ulcerates, while the latter as a rule does. The
bright yellow discharge from the lesions is said to be characteristic.
Prognosis
Tlie scrofulous habit must be antagonized and if this can be done
the prognosis is good.
Treatment
The usual regimen is prescribed. The best remedy is rest. The
ulcers heal up under mild antiseptics and ointments which encourage
granulation.
Fig. 157. Model in Freiburg Clinic (Vogelbacher).
200
Plate 97.
Fig. 158. Scrophuloderma.
Fig. 159. Papulonecrotic tuberculide.
i
i
Scrofuloderma
Plate 97, Fig. 158
This term has been and is still rather loosely applied. It should
be a generic term for all the cutaneous lesions which are clinically
allied to scrofula in general. From this viewpoint affections like
erythema induratum, and lichen scrofulosorum should be the leading
representatives. From a narrow viewpoint the term is only applied
to the cutaneous lesions which follow the rupture of a scrofulous
abscess due to suppurating lymph nodes. Scrofuloderma is supposed
to be different both from true tuberculosis of the skin and from the
tuberculides so-called. The term is here applied to lymphoid swell-
ings whether of original subcutaneous lymph nodes or independent
formations in or under the skin. When these formations undergo
caseation and indolent suppuration results, the overlying skin be-
comes thinned and livid and eventually gives way. There remain cer-
tain ulcers or shallow sinuses, the latter often multiple. The skin
about them has a peculiar purplish color, the ulcers are undermined,
granulate imperfectly, and have but a scanty secretion. Sometimes a
fragile cicatrix forms. In these cases we may see supervene the so-
called inoculation lupus or even an active tuberculosis, showing the
close relationship of all these processes.
In certain patients who seem, while fairly healthy, to have been
ravaged by the most polymorphous type of scrofula, so that hardly
any tissue seems to have escaped, a peculiar eruption of papulo-
pustules occurs, resembling most closely a syphUide of the same
character. Before the introduction of the term tuberculide, this
affection was termed by Duhring and Bulkley scrofuloderma. By
exclusion it could be showm to be none of the kno-wn affections
and the eminently scrofulous character of the subjects, who seem
never to have had any other illness than some form of scrofula, causes
the diagnosis of scrofuloderma. The affection consists of small
papulopustules, of a torpid character, livid or brownish, scattered
sparsely over the face, trunk and limbs. The lesions leave scars.
201
Diagnosis
The ulcerative lesions often resemble syphilis, but this disease
should be readily excluded by the absence of other symptoms.
Treatment
The general health of the patient should be improved. Cod-liver
oil, iron, arsenic, hypophosphates, etc., are indicated. Locally the
lesions should be treated on general surgical lines.
Fig. 158, Model in Neisser's Clinic in Breslau (Kroengr).
202
Papulo-Necrotic Tuberculide
Synonyms : Folliclis, Necrotic granuloma
Plate 97, Fig. 159
The papulo-necrotic tuberculides belong to a large group of skin
manifestations, showing a great variety in appearance, but possessing
many similar characteristics. They are frequently associated with
tubercular manifestations elsewhere, such as tuberculous disease of
the lymph-glands or lungs. The essential, and most frequently seen
lesions are small, indurated, extremely indolent granulomas, showing
a tendency to undergo central softening and necrosis. The site of
each resolved lesion is marked by a prominent depressed, punched-
out scar, much like that of variola. The lesions are bilateral and
rather symmetrical. They appear most frequently on the upper
extremities, particularly the forearms and hands. They occur mostly
in individuals of scrofulous habit or history, and are frequently
met with in chlorotic factory girls, with a depressed peripheral
circulation.
The relationship between the tuberculides and tuberculosis is a
very close one, but the exact nature of this relationship is unknown.
Histologically, giant cells and a tuberculous architecture have fre-
quently been demonstrated, but the tubercle bacillus has not been
found. Many cases show only changes incident to simple inflam-
mation.
Diagnosis
The symmetrically distributed indolent papules, with necrotic
centres, and variola-like scars, together with the history and course
of the disease, will serve to differentiate it from syphilis.
Prognosis
The disease is extremely chronic, and may continue for years.
Treatment
As the disease occurs mostly in those in poor general health,
fresh air, sunshine, and good food are of prime importance. The
203
internal remedies vary wath the indications of each individual case. |
Cod-liver oil and iron are frequently used, and are often of decided ^
value. Tuberculin therapy has apparently cured, or greatly improved, j
a number of cases. Ammoniated mercury ointment, in from five to *
ten per cent, strength, has proved the most valuable local application. >
Antiseptic washes of mercuric chlorid (1:5000) or boric acid have
been used. Curetting, with the subsequent application of pyrogaUol '[
salve has been recommended. Where the lesions are few excision may \
be practised. Good results in some cases have followed the applica •■ '
tion of the Finsen-light treatment. The X-rays are of less value.
Fig. 159. Model in Neisser's Clinic in Breslau (Kroener).
204
Plate 98,
Fig. 160. Ulcus endemicum (ropicum.
Ulcus Endemicum Tropicum
Plate 98, Fig. 160
Under this designation we find comprised a number of conditions
old and new: the Biskra button, Aleppo evil, oriental boil, etc., and. in
recent years "Leishraaniosis ulcerosa, cutic," due to the fact of its
trypanosome origin.
From the earliest records, we have known that various local condi-
tions, which closely resemble one another, impose themselves upon us
as separate affections, having separate local designations. These
affections may be traced from Morocco to the Ganges. Briefly
summed up we have to do with chronic ulcers, sometimes multiple, on
exposed localities. Some sort of insect undoubtedly acts in propa-
gating this affection, not only from one subject to another, but in the
same individual. The lesion, at first an itching papule, becomes in
time a broad, itching pustule, covered with a crust. Kemoval of the
latter shows a deep ulcer of uneven surface and various shades of
color. Smaller pustules appear at the periphery, break do■\^^l and
become continuous with the mother pustule, increasing its area so
that it may attain a diameter of several inches. The latter may
slowly heal, perhaps only after years.
Diagnosis
This lies in recognizing the extreme chronic occurrence of a sore
on an exposed surface.
Prognosis
Although extremely chronic the ulcers sometimes heal sponta-
neously.
Treatment
Destruction of an entire structure.
Fig. 160. Model in St. Louis Hospital in Paris (Baretta). By permission
of Dr. Beurmann, from Iconographia dermatologica, No. TV.
205
Lepra
Synonyms: Leprosy, Elephantiasis Griecorum, Leontiasis, Satyriasis,
Spedalskhed
Plate 99, Figs. 161, 162; Plate 100, Figs. 163, 164; Plate 101,
Fig. 165; Plate 102, Fig. 166
This is one of the oldest endemic affections, and from its disfigur-
ing effects is readily recognized as the elephantiasis leontiasis and
satyriasis of the Greeks. The connection between this disease and
the. satyrs of mji;hology is obscure ; it may have referred to the fact
that lepers were forced to shelter themselves in the depths of the
woods, and this with their deformed appearance possibly suggested
the opprobrious appellation. The usual explanation that lepers suf-
fered with inordinate venereal desires, therein resembling satyrs, is
not in accordance with facts, the contrary being the ease. This,
however, may have been the popular belief. The- word lepra meant
to the .Greeks only a scaly affection, probably psoriasis. The word
lepra was. first applied to leprosy by the Arabians, who confined the
term elephantiasis to a different disease (filariasis). Much ingenuity
has been displayed in trying to identify biblical leprosy, which
probably comprehended a number of chronic skin diseases character-
ized by scaling or mere whiteness without scaling. Hence both
psoriasis and vitiligo might belong here. The confusion vrith true
leprosy doubtless arose from the fact that in the prodromal and early
stages of leprosy, peculiar eruptions which simulated benign derma-
toses are very common. Not less vague was the significance of
medieval leprosy, and it is hardly worth while to attempt to trace the
exact source of our present conception of the disease.
WhUe there are two quite distinct varieties, of true leprosy, the
tubercular and the anesthetic, the latter was probably known in
earlier times only in mixed cases. The purely anesthetic type is so
unlike tubercular leprosy that it shoxdd be separately considered.
Lepra Tuherosa
This type of leprosy belongs to the infectious granulomata and
resembles other members of the group, notably syphilis and tubercu-
losis in various ways, and especially in its ability to attack almost
the entire integument with the upper air and food passages, involving
destruction of the facial bones. If we bear in mind what tertiary
206
j: i<«i.^ 7t
/
Plate 100.
3
C
<1)
syphilis is, it wUl at once become apparent that when the tubercles
and nodules of leprosy appear in the skin, the disease should already
be old, and in a late stage of development.
The word tertiary is justifiable if we accept the theory of prom-
inent authorities as to the primary lesion of leprosy; the secondary
stage would imply the date of the infection of the blood. Before the
tubercular lesions appear there are vague symptoms which point to
the presence of a toxemia", no doubt coinciding with the blood infec-
tion ; while paresthetic sensations of all kinds show an early implica-
tion of the nerves at some point in their course and distribution. In
some cases there is a transitory eruption of an erythematous type
which is seldom recognized. At a later period macules appear,
which are permanent and eventually become the seat of tubercles.
These vary greatly in color, contour, etc., and often simulate ordinary
eruptions. There is usually an increase of pigmentation, which asso-
ciated with hyperemia gives rise to red and livid blotches on the one
hand, or brown, black or slate-colored areas on the other. The
individual lesions show the greatest variation in size and details in
general. The amount and character of the'pigmentation may suggest
a number of affections, but the leprous nature is usually -recognized
at once by the anesthesia.
The macules are by no means a constant phenomenon, and when
the individual with developed leprosy appears he usually presents
quite a different picture. The face is the part to manifest the tuber-
ous process, as a rule, and the tubercles may appear in one of several
localities, sooner or later symmetrically. In one patient there may
be, for example, a few flesh-colored tubercles, closely grouped, over
the cheek bones. The lobe of the ear is also a favorite early site, and
merely feeling of the lobes is one of the routine ways of arriving at
a diagnosis. Instead of these circumscribed groups, we may see a
general infiltration of the skin of the forehead, especially of the eye-
brows, or of the nose, lips or chin. There appears to be no law
governing the choice of location or order of evolution. When the
process is sufficiently diffuse and deep-seated the appearance is typi-
cal of the disease, and is described by the term leontiasis. In some
cases, however, the features which give to the face its expression
are but little affected, although there may be very many tubercles
on the forehead, cheeks and chin. The greatest disfigurement results
from the corrugation of the forehead, the loss of the eyebrows, which
is practically constant, the infiltration of the upper eyelids, the
spreading of the nose and thickening of the lips. All of these may
occur in the same subject, and in the most extreme development the
207
entire face is uniformly thickened and lobulated by folds like that of
a pachyderm — hence the designation elephantiasis.
During the appearance of the tubercles on the face there is
commonly a similar evolution in the nasal chambers, mouth and
throat, and the early perforation of the septmn is sometimes regarded
as the primary lesion of the disease, but this is unlikely. Loss of the
nasal bones occurs, as in lupus and syphilis, in a certain proportion
of cases. There is also a marked tendency to lepra of the larynx,
producing aphonia, and frequently there is also destruction of the
sight.
Despite the. severity of leprosy in the face and its accessory cavi-
ties, the scalp enjoys almost an immunity. The deposition of the
tubercles is usually preceded and accompanied by pigment anomalies,
but these are of minor significance. Tubercle and nodules occur
in aU localities outside of the face, and the nodules may reach the
size of tumors. The diseased surface is prone to form intractable
ulcers. The skin at large may also be uniformly thickened. Thus, in
one leper .the hands and fingers may retain their normal contour and
yet be the seat of many tubercles and nodules, or the entire hands
may be swollen out of shape, the fingers resembling bananas. The
participation of the lymphatics plays a considerable role in leprosy
as it does in leukemic tumors and mycosis fongoides. When these
are involved the amount of swelling and thickening is greatly
increased.
Lepra Anestheiica
It is of course understood that the so-called anesthetic or nerve
leprosy may complicate ordinary tubercular leprosy, in which case
its manifestations are overshadowed by the severity of the latter
affection. It is also understood that in exclusively tubercular leprosy
there is always implication of the terminal nerve filaments, so that
anesthesia is a constant symptom. "What is meant by lepra anes-
thetica or nervora, in the strictest sense of the term, is a limitation
of the disease to one or more nerve trunks, or in other words isolated
leprous neuritis. This is a not uncommon type of the disease which
presents no further deformity than results from this one class of
lesions. The subjects, often superior in their station, may be found
in schools or offices or in society, with no one, not even themselves and
their families, aware of the nature of the malady. The patient seem?
to develop the disease in the usual manner, i.e., with obscure evidences
of toxemia. They may also have the prodromes and early maculo-
anesthetic lesions, but tubercles never develop. The bacillary or
toxic cause of the disease is neurotrophic only. A neuritis develops,
208
Fig. 165. Lepra ariaesthetica.
just as it may in a number of diseases. A pemphigoid eruption often
attends the supervention of the neuritis.
The patients usually present themselves after the neuritis is
fully developed. If seen early enough there may be present the
indefinable toxic symptoms, the paresthesiaj and the preliminary
maculo-anesthetic eruption on the trunk. The latter is not so marked
and deep-seated as in lepra tuberosa, and does not present such wide
diffusion or deep stains. Great variety is shown, however, in color
and extent and presence of an atrophic element which causes lesions
suggesting vitiligo and morphea. There is also considerable variety
in the sensory disturbances, which may be hyperesthetic or pares-
thetic at first, but end in anesthesia. One nerve only, usually the
ulnar, is involved, and there may be found some macular lesions on
the face, or perhaps not even that — only subjective anesthesia in
limited areas. When a particular nerve trunk like the ulnar is
involved, the picture is simply that of a severe, persistent neuritis
with eventual trophic alterations, perhaps of the highest type. It
is doubtful, however, if a single detail is characteristic of leprosy.
The claw hand, the sloughing of the phalanges, the perforating ulcers
of the sole of the foot, when the peroneal nerve is involved, are
shown to be of leprous origin only by collateral evidence and exclu-
sion. The neuritis of the ulnar and peroneal nerves is fully devel-
oped, but analogous lesions on the face and trunk are much less
typical, suggesting morphea or hemiatrophia facialis. On account of
our ignorance of many localized trophic affections, a few authors
look upon them as survivals of nerve leprosy. Syringomyelia, with
its anesthesia and trophic lesions on the hands, resembles nerve
leprosy, but is synometrical while the latter may be unilateral. There
appears to be no reason for pure nerve leprosy being fatal. Subjects
admittedly have lived twenty or more years.
Etiology
Leprosy is due entirely to the parasitism of Hansen's bacillus,
which can now be cultivated and inoculated. The baciUus greatly
resembles that of tuberculosis, and in animal experiments the two
may be made to produce much the same lesions. All attempts to
trace the passage of the germs into the human body have been
unavailing. Although leprosy is prevalent in hot countries, this fact
is a mere coincidence, for the disease also flourishes in the coldest
countries. The abimdance of insect life in hot countries and the
huddling together of people in vermin-infested huts in cold climates
strongly suggests the intermediation of insects. There is no initial
or parent lesion known in leprosy, as in some of its congeners.
209
Whatever the mode of transmission, there is a notable immunity to
the disease on the part of relatives and neighbors, and tliis may be
an acquired immunity, for we know nothing of any minimal forms of
the disease. The familial character suggests also an inherited
disposition to the malady.
Diagnosis
Only in the earliest stages is there any difl&cnlty, and this usually
in non-leprous countries. In the long prodromal period there are
many vague symptoms suggesting a chronic or recurrent toxemia,
which most naturally remind one of malaria, while the paresthesias
may suggest various affections of the nervous system. If there is
a pronounced macular stage antedating the tubercles, the presence of
anesthesia is significant. There should be a special examination of
the septum for a lesion, also of the skin of the face for the first
tubercles. The ulnar nerve is sometimes felt to be thickened at the
internal condyle. During the first evolution of the tubercles on the
face, both syphilis and lupus may be simulated, but not to such an
extent as to lead to confusion. The tuberculin test is negative in
lepers, except in those who are also suffering from tuberculosis, but
the Wassermann reaction is generally positive, especially in the
nodular type of the disease.
Prognosis
Leprosy tends to appear in successive exacerbations. One of
these may not amount to a confirmed disease, for in very rare cases
there is no succession. These self-limited cases may be responsible
for erroneous ideas of treatment. The affection once developed is
practically incurable. Despite the malignity of the disease, vital
organs are not attacked, and although the patient is literally dying
by inches and menaced by a score of other diseases by reason of
his low vitality, he may live many years, the average being eight or
nine or even more. The anesthesia robs the disease of much suffer-
ing, but the patient, largely disabled by his infirmities and ostracized
by society, is reduced to continued martyrdom. In about half the
cases death occurs from tuberculosis. The leper somehow develops
immunity to septic infection to which he is constantly exposed, and
cancer is almost unknown among them.
Treatment
"VMiile segregation protects the commimity at large, emigration
benefits the individual leper. Change of residence to a non-leprous
country or otherwise healthy climate invariably lengthens the life
210
of the patient and lessens the severity of the disease. The reverse
is true when the patient remains in a locality where leprosy is endemic
or when a victim of the disease is forced to associate with other
lepers.
In addition to the best dietetic and hygienic management, and the
treatment of symptoms as they arise, the various drugs generally
recommended as antileprous remedies should be employed. The
best accredited of these is chaulmoogra oil. Symptomatic betterment
nearly always follows the use of this oil, and some believe that by
perseverance a technique may be devised by which it may become
a veritable specific, attacking the bacillus in all the tissues. At
present the great drawback to the use of oil is the frequency with
which it causes gastric disturbance. As it should be given in large
doses, its administration subcutaneously or by inunction is not very
satisfactory. Gurjun oil and hoang-nan are drugs that have been
extensively used in leprosy. Crocker strongly recommends the intra-
muscular injection of bichloride of mercury.
In the anesthetic type of the disease improvement has sometimes
followed the administration of large doses of nuc. vomicae. Arsenic
has often been used for its general tonic effect, and in some cases of
tubercular leprosy apparent improvement has followed intravenous
injections of salvarsan. The X-rays have been largely used and are
now known to be of considerably less value than was formerly sup-
posed. Nastin, prepared from a streptothrix found in leprous
nodules, has recently attained considerable attention as an antileprous
remedy. Its therapeutic value, however, has not as yet been definitely
determined. Serums and vaccines are still in the experimental stage.
Fig. 161. Model in Lassar's Clinic in Berlin (Kasten).
Fig. 162. Model in Neisser's Clinic in Breslau {Kroener).
Fig. 163. Model in St. Louis Hospital in Paris, No. 1000 (Baretta).
Lailler's case. A leper from the Isle of Bourbon.
Fig. 164. Model in St. Louis Hospital in Paris, No. 1217 (Baretta). Vi-
dal's case. A leper from Calcutta.
Figs. 165 and 166. Models from Neisser's Clinic in Breslau {Kroener).
The daughter of a fisherman from the neighborhood of Memel, aged
seventeen, with disturbances of sensibility; wasting, especially of the
arms and legs, noticed for a year and a half; pigmentary and blanched
areas on the trunk; atrophy of the hands, especially of the thenar,
hypothenar, and interosseous muscles.
211
Rhinoscleroma
Plate 102, Fig. 167
This affection, which is often at the present day termed simply
scleroma, because it is not peculiar to the nose nor does it necessarily
begin in that organ, was originally seen only in certain localities in
Eastern Europe, where at first it seemed to affect only Orthodox
Jews. At a later period it was found farther west, and also among
other races, and it is now known to occur in Central and South
America. From its original locality in Europe it has also been
carried into various countries, the United States included, by immi-
grants.
Rhinoscleroma is limited to the nose, pharynx, larynx and trachea,
the same area in fact to be attacked by ozenous affections with which
it is thought to be in some way related. It may be primary in any
of these localities, but in about ninety per cent, appears first in the
nose. Its location here is the only one of dermatologic significance.
It begins in the mucous membrane, from which locality it involves
the cartilages and soft parts of the nose. These structures are infil-
trated with extremely hard neoplastic tissue, and the process may
extend to the lips, the nose becoming broad and the nostrUs narrowed.
The actual lesion is a flattened nodule and these may remain isolated
or be crowded together.
The description thus far given follows that found in dermatologi-
cal works. It is, however, a serious error to regard this affection as
one which primarily concerns the dermatologist, who sees as a rule
only such advanced forms as have involved the face. The rhinolarjm-
gologist is bound to see a greater number of cases than does the
dermatologist, for he sees the types which have not attacked the skin.
The affection, in fact, is one of the nasal cavities which may extend
either forward or baclrward. It seldom climbs upward, so that the
olfactory portion of the nose is non-participating.
The primary focus is most commonly found on the anterior region
of the floor of the nose, or from the continuous portion of the septum
and the contiguous area of the inferior turbinal. Even when its
212
Plate 102.
E
o
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OS
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3
G.
development has not transcended this locality, it is recognized by
the rhinologist. In tlie meantime it advances in growth within the
nasal chambers, and in many cases extends backward to involve the
pharynx and larynx.
The affection tends to appear in nodules, discrete or confluent,
which cause much deformity through the resulting thickening of the
various tissues attacked, but seldom leads to secondary changes of
any sort. Ulceration does not often appear.
Etiology
The primary prerequisite seems to be squalor, Eace is no longer
believed to be a prominent factor. A characteristic bacillus appears
to be the efficient cause, one which differs in no wise from the bacillus
ozense and bacillus of Friedlander pneumonia. Once thought to be
a disease of adult life, it is now known to attack children.
Diagnosis
This could undoubtedly be made by exclusion in cases of doubt,
but when well developed the nature of the condition should be evident.
Treatment
The disease cannot be extirpated surgically, for new nodules are
bound to reappear. The troubles caused are entirely mechanical, and
hence nasal and laryngeal obstruction have to be prevented, if pos-
sible. The treatment may be summed up in radiography and auto-
vaccino-therapy, which sometimes serve at least to clear up the
obstructions to breathing.
Fig. 167. Model in St. Louis Hospital in Paris, No. 1615 (Baretta).
Besnier's case.
213
Leukemia Cutis
Plate 103, Fig. 168
The general condition known as leukemia, from the initial blood
state, is characterized by lymphoid tumors of certain structures along
with a general IjTiiphoid infiltration of the viscera. Exceptionally
both these features are seen in the skin, and the resulting condition
of the latter bears a not inconsiderate resemblance to certain cases
of multiple sarcoma and granuloma fungoides. The earliest manifes-
tations in the skin, whether or not due to interference with the IjTuph
circulation, sometimes consist of a dermatitis or eczema, which itches
intensely, and becomes infiltrated with time. These eruptions, how-
ever, do not pass directly into lymphomatous lesions, as might be
expected from the analogy with granuloma fungoides. An irregular
thickening of the skin from participation of the lymphatics also
occurs without previous dermatitis. Both the dermatitis and the
elephantiasis lesions occur in more or less circumscribed areas.
Tumors occur in two principal forms. In one, the lesions are small,
in size up to a cherry and very numerous, sometimes arranged in
series. The other consists of individual masses which may attain
large dimensions. All these lesions, which depend evidently on more
or less common factors, may occur singly or in combination. The
head and face, arms and genitoanal region are the localities of choice.
Occurring in the face a condition of leontiasis results. The affection
does not necessarily have a leukemic basis, for the same lesions occur
in pseudo-leukemia or Hodgkin's disease. Despite the severity of
the condition the lesions do not appear to undergo much retrograde
change nor do they seem to be able to increase indefinitely. In any
case death from the underlying disease would take place before such
results could transpire. The prognosis for recovery is hopeless.
Diagnosis
In any of the affections of this tj-pe a blood count must be made
to exclude granuloma fungoides and pseudo-leukemia. There is little
doubt, however, that all these affections form a group disease.
214
Plate 103.
Fig. 168. Leukaemia cutis.
Treatment
The X-rays are much used at present for the general condition of
leukemia, and from their power over neoplasms they furnish almost
our sole resource. Arsenic injections have a certain influence in some
cases.
Fig. 168. Model in Neisser's Clinic in Breslau- (Kroerur).
215
Granulomo Fungoides
Synonym: Mycosis fungoides
Plate 104, Fig. 169; Plate 105, Fig. 170
This very rare affection, first described by Alihert in 1814, pre-
sents some notable analogies with leukemia of the skin and pseudo-
leukemia, resembling these more than multiple sarcoma -ft-ith which
it has sometimes been confused. In a few cases a leukemia blood
picture has been found in tj-pieal granuloma fungoides. The most
remarkable parallelism with leukemia lies in the initial pruriginous
eruptions. These manifestations in the case of leukemia are said to
point to an underlying systemic infection. In the polymorphous
character of these exanthems, their occurrence in successive crops,
the intense itcliing, and the chronic intractable character, we are
reminded of some features of dermatitis herpetiformis. Eczema has
also been exactly simulated, and even psoriasis. These eruptions
may be more or less generalized or narrowly circumscribed. This
preliminary phase lasts for months or years, crops of eruption suc-
ceeding one another, until at last the presence of infiltration is noted,
at first in small areas, causing flat nodes from pea size to that of a
cherry. We see something of this sequence in other granulomata of
the skin — superficial eruptions followed by nodulation. The nodules,
however, in this case become distinct tumors, the tendency of the
former being toward aggregation into patches. Tumors, however,
may also arise from apparently healthy integument. Here, too, it
may be emphasized that the so-called premycotic stage is sometimes
lacking, the disease begimiLng entirely as multiple tumors. Notwith-
standing their formidable characters, they sometimes undergo involu-
tion. With the appearance of tumors there is no extinction of the
premycotic manifestations which continue to appear. The first
tumors are small and not numerous, but others soon appear and the
entire surface may in time be studded with them. They tend to be
larger in successive crops and more disposed to retrograde changes.
They vary much in appearance and have been likened to various
216
7;„ 1 An r^r-oniilnrm fiiiHTniHp';
objects, as tomatoes, there being a tendency to lobulation. The
appearance presented by tumors is not to be confused with the
changes which supervene after ulceration. The latter is not a uni-
versal process, else the patient would hardly be able to maintain his
general health. It is perhaps exceptional that a tumor softens and
ulcerates at the summit, after which the proliferation from the ex-
posed surface is of a fungoid character. In certain cases, however,
the mushroom-like lesions may predominate, so that as in Alihert's
first case there was a condition like yaws. The patient's general
health, often maintained throughout, now begins to succumb to maras-
mus, and death ensues.
Eiiology
The disease is regarded by many as being of parasitic origin,
although this as yet has not been proved. The general aspect of the
affection is much like that of sarcoma. Blood changes are sometimes
seen in granuloma fungoides but they show variable pictures. The
blood changes sometimes seen — eosinophUia, polynucleosis, etc., are
only such as may accompany toxic, infectious, and other obscure
chronic diseases. As a matter of fact they differ in nowise from
blood pictures seen in syphilis and tuberculosis.
Next in interest to the blood pictures are the visceral lesions.
The aggregate amount of study which has been bestowed on these is
not extensive. Many of the changes are only such as would naturally
be found in any chronic constitutional disease. The question as to
whether do actual metastatic growths occur which are identical with
those of the skin is naturally of the greatest importance. Lymphoid
hyperplasia has been found at times which, however, presents nothing
specific. It cannot be said that any of the questionable finds duplicate
throughout in structure the tumors of the skin. There are, however,
a few cases on record in which careful histological study of the
viscera has revealed lesions which conform in every way to the
cutaneous growths. Bosellini found such changes in the cortex of
the brain which he regards as possessing analogy with luetic and
tuberculous gummata in the same locality.
Diagnosis
In the early stage the affection may bear a very decided resem-
blance to eczema, psoriasis or urticaria. In the stages of infiltration
and tumor formation, however, the condition is unique and a diag-
nosis may be made by exclusion. The microscopical picture is char-
acteristic even in the early stage and a biopsy should always be made
in suspected cases.
217
Prognosit
The duration is very nncertain, depending largely upon the period
at which the fungoid stage develops. After this has appeared death
is a question of months, the utmost survival being perhaps two years.
Treatment
Constitutional treatment consists essentially in the nse of tonics
combined with a generous diet.
The X-rays have a very decided influence upon the sjonptoms and
lesions of the disease. In the early stage the pruritus is greatly
relieved and in the late stage the tumors may be made to practically
disappear, A few years ago it was thought that with the X-rays a
symptomatic cure could be obtained, and many of the highest authori-
ties still look upon their employment with favor. In cases that have
been imder my own observation, however, I am convinced that death
followed the apparent improvement obtained by the use of the rays
more rapidly than would otherwise have been the case.
Arsenic is generally recommended, and has been used extensively,
sometimes with benefit. It should be given in large doses, internally,
and by subcutaneous injection. In one of my cases very decided
improvement followed intravenous injections of salvarsan. Potas-
sium iodid is occasionally of value in the fimgoid stage.
Local treatment is merely palliative. In the prefungoid stage,
the various antipruritic remedies used in eczema may be employed.
In the late stage ablation of the ttmiors may be performed or the
growths destroyed by the thermo- or electro-cautery. When the
tumors break down antiseptic applications and dressings are indi-
cated. Dry dusting-powders are often useful.
Fig. 169. Model in Neisser's Clinic in Breslau (Kroener).
Fig. 170. Model in St. Louis Hospital in Paris, No. 1706 (Baretta).
Hallopteau's case.
218
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Plate 106.
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Sarcoma Cutis
Plate 105, Fig. 171; and Plate 106, Fig. 172
Four varieties are described of sarcoma cutis based upon the pres-
ence or absence of pigment and whether or not multiple.
Single, non-pigmented sarcoma is a very rare affection and not
highly malignant. It usually develops in a previous lesion — mole or
wen, does not run to any particular type or types, varies extremely in
size, shape and location, seldom attains a size larger than a fist and
tends to be fatal through internal metastases.
Single pigmented or melanotic sarcoma is a much more typical
affection which may begin in a pigmented mole, but often first appears
on the hands or feet as a bleb or felon-like lesion. Pigment is so
essential that it may be noted before there is any tumor. The primary
lesion not only grows with great rapidity, but metastases quickly
appear, even in the skin and mucosae. Aside from secondary tumors
there are simple deposits of pigment.
Generalized or multiple non-pigmented sarcoma has no connection
with any other form of sarcoma cutis and begins with a number of
separate growths near together. Some of these cases appear to be
leukemic in origin, others resemble more or less closely granuloma
fungoides. Others again may be multiple cutaneous metastases of
internal sarcoma. All in all, the nosologic position of this affection
is not clear. Affections described under this name are relatively
malignant. The lesions, unlike typical sarcoma, have considerable
tendency to ulcerate before they attain much size. The inflammation
which sometimes develops about these growths and the intense itching
often present has caused them to be termed pseudogranuloma fun-
goides. The fourth form, idiopathic multiple hemorrhagic sarcoma
is much more readily characterized than are the preceding. It begins
on the extremities in multiple foci, showing various shades of blackish
or bluish. The earlier lesions may in part undergo involution, but are
soon followed by others. The limbs may be so studded as to consti-
tute a form of elephantiasis. An angiomatous or telangiectatic new
2119
formation commonly coexists, so that the tmnors bleed easily. The
course is less malignant than in the other forms, for the patients
often survive for many years.
Etiology
Absolutely nothing is known of the intimate nature of these affec-
tions, beyond what is kno\\Ti of malignant disease in general. They
occur at any age, and are much more common in males, large, vigorous
men being often noted among the subjects.
Diagnosis
Aside from a few allied forms of malignancy — ^leukemic tumors
and granuloma fungoides — there is no affection which should give
rise to confusion, save, of course, in the very earliest stages.
Prognosis and Treatment
Save in the case of isolated non-pigmented sarcoma, there is no
real remedy, not even early excision, which seems to precipitate the
extension of a pigmented sarcoma. A few cases of cure have been
attributed to arsenic injections. Some of the earlier nodules dis-
appear spontaneously, so that it is credible that very exceptionally
there may be no recurrence, and the affection is self-limited. This
fact does not furnish any indications for successful treatment. In
idiopathic multiple hemorrhagic sarcoma improvement sometimes
follows the use of the X-rays.
Fig. 171. Model in Neisser's CUnic in Breslau {Kroener).
Fig. 172. Model in Lesser's Clinic in Berlin {Kolbow).
220
^
b
Plate 107.
-o
o
Ulcus Rodens
Plate 107, Figs. 173 and 174
This affection is a special clinical type of epithelioma of the skin,
which was originally confounded with lupus and termed lupus exe-
dens. Its ultimate recognition was due chiefly to the microscope, for
cHnicaUy it has considerable analogy with lupus, and the confusion
is heightened by the fact that an ulcerated lupus lesion not infre-
quently becomes an epithelioma. Some authors make a distinction
between rodent ulcer and superficial epithelioma, but for clinical
convenience it is best to regard the former as a mere variety of the
latter, in which ulceration of a progressive character is the essential
part of the disease, which may therefore cease to be superficial,
although never becoming cancerous in the strict sense. While super-
ficial epithelioma may develop elsewhere in rare cases, it is practically
limited to the face and chiefly to its upper half.
The disease, like any form of epithelioma, may begin in a pre-
existing lesion — as a seborrheic wart, but as a rule first appears as
a characteristic lesion — a nodule of a peculiar pearl-like lustre, but
sometimes of a reddish, yellowish or brownish hue. These nodules
are elevated and sharply defined, and not mere circumscribed infil-
trations. They are softer than the surrounding tissues, from which
they are readily scraped away with the curette. In this, as in other
respects, a comparison with lupus vulgaris is inevitable ; but this is
hardly worth while, because the latter almost always begins in child-
hood, while epithelioma is a disease of advanced life. In rodent ulcer,
loss of substance is evident from the first, and the destructive process
may be quite rapid, so that a flat, raw surface quickly appears. A
characteristic of rodent ulcer as compared with the ordinary form is
the lack of any attempts at repair. There may be nothing at first
sight about these ulcers to throw any light on their nature, although
the fact of their occurrence about the eyelids or sides of the nose or
temples in an elderly subject would at once suggest the disease. In
221
some cases, however, a thin, pearly border is in evidence ; and it be-
comes apparent that the tendency of the disease is for the degenerated
tissue to ulcerate before it can become visible to the naked eye. This
feature, coupled with the frequent inability of the centre of the lesion
to cicatrize and the occasional tendency to attack the deeper tissues,
suffices to differentiate rodent ulcer from the alternate form of the
disease, Eodent ulcer has but little discharge, and this dries into a
thin, adherent crust.
The typical form of superficial epithelioma is a much more chronic
affection. The pearl-like nodules may persist for months -without any
tendency to break down, and are replaced very slowly by small losses
of substance. A thin adhesive crust usually covers the latter, and
reforms promptly when detached. The ulcer extends very slowly
and new nodules at the periphery may often be seen to precede this
extension. As the ulcer becomes larger, its entire border may be seen
to be constituted of this new tissue. Another more or less characteris-
tic feature is the marked tendency of the ulcer to undergo cicatriza-
tion and retraction. It is not uncommon to see a case even untreated
in which a large area of scar tissue makes up nearly the whole of the
lesion, while only here and there does a small incrustation, raw sur-
face or group of new nodules proclaim the active state of the process.
Naturally, aU attempts to separate wholly the two forms of
superficial epithelioma from each other or from the deep forms are
more or less unsatisfactory because transitions sometimes occur.
Rodent ulcers practically never cause metastases of the IjTiiph nodes,
and on account of their chronic course in people already advanced in
years seldom destroy life.
Diagnosis
One set of difficulties is connected with the initial manifestations,
and chiefly when these occur secondarily to some preexisting lesion —
a wart or mole. However, aU signs of activity in old lesions are uni-
formly regarded as suspicions of a precancerous state. In senile
warts which do not manifest themselves until advanced age it is more
difficult to recognize precancer — in fact, impossible. The most sig-
nificant sign is the appearance of a small crust, which announces the
presence of an underlying abrasion or fissure, and which quickly
reforms when detached. Other difficulties are connected with exclud-
ing syphilitic and tuberculous ulcers, which may themselves develop
into epithelioma. Serological tests should be of help in certain
obscure cases.
222
Prognosis
This depends much more on the opportunities for proper treat-
ment than is the case with many affections because of the great
chronicity and relative benignity of the process. Seated Ln localities
which forbid excision as a rule, these lesions are nevertheless curable
in the great majority of cases, even when quite far advanced. Left to
themselves or improperly treated, there is barely any tendency to
improve.
Treatment
While these affections are not believed to originate from local
irritation to any marked extent, it is none the less true that they some-
times improve notably under soothing applications. These cases are
naturally those which have been aggravated by improper treatment,
and are much more coromon among deepseated cancers. The old name
of "touch me not" applied to rodent idcer shows that these were
readily aggravated by improper treatment.
For beginning lesions and those which have not surpassed a cer-
tain size the principal resource is the curette, followed by chemical
cauterization. This in the majority of cases is enough to cure the
condition as it stands, although new nodules may appear later.
A large rodent ulcer may be excised outright in suitable localities.
In others the raw surfaces may be destroyed by the use of the
curette and caustics as before, but in recent years X-rays have been
extensively used, alone and in combination with mild caustics, and
are adapted especially to cases where severe measures would produce
deformity and functional incapacity.
Figs. 173 and 174. Model m Freiburg Clinic (Johnsen). Patient came
from Jadassohn's Clinic in Berne.
229
Paget's Disease of the Nipple
Sjnonjm: Malignant papillary dermatitis
Plate 108, Fig. 175
This affection should be given its full title, as Paget's name is also
associated with another, though quite dissimilar disease, osteitis
deformans.
The affection of the nipple was first described by Sir James Paget
in 1874 in a paper based on the study of fifteen cases, and it was
originally regarded as an eczema of the nipple and areola, to which
carcinoma of the mammary gland is frequently consecutive. It is
now knoT\Ti to be a malignant process practically from the beginning;
a superficial new-growth "with a peculiar precancerous inflammatory
phase.
The disease is not necessarily limited to the female nipple nor to
the reproductive organs as a class, but is one that may occur in
almost any locality. Cases have been recorded of its attacking the
scrotum, penis, anus, axillae, umbilicus, as well as other parts. Its
immediate interest, however, lies largely in the original disease as it
affects the nipple.
In seventy-five per cent, of cases the right nipple is attacked, a
disproportion at present inexplicable. The eczema-like patch which
first forms about the nipple is very insidious in its development and
for a long time may present only a scaly erythema which itches more
or less. Its circumscribed area is due in part to the fact that it is at
first confined to the areola. It passes beyond the latter in some
cases, but not far in its eczematous phase. The second stage presents
a surface like eczema rubrum, raw and moist. The true nature of the
process may generally be recognized at this stage by the sharp con-
tour and slight sense of induration. The nipple also undergoes
changes which could never result from mere eczema, being eroded
and retracted. The disease now ulcerates and extends over the sur-
face of the breast while at the same time it passes along the ducts
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and involves the gland proper. As ulceration is taking place about
the nipple the eczematous area may be extending at the periphery.
It is probable that at the present day most of these cases come to
treatment long before extreme stages are reached.
Etiology
The disease attacks the same victims as does ordinary cancer of
the breast. Beyond this nothing is known as to causation, although
it may be taken for granted that any kind of irritation of the nipple
is a causal factor.
Diagnosis
No confusion should arise save in the earliest phase of the disease.
At this time, when there is only a slight scaly patch with a Little
viscid secretion, the condition might easily be confounded with ec-
zema or dermatitis. The test of treatment should be of value here,
as an eczema or dermatitis should readily yield to appropriate
treatment.
Prognosis
If seen early and treated radically the growth may generally be
removed. The prognosis, however, in old, extensive, and neglected
or badly treated cases is always unfavorable.
Treatment
No permanent good can result from the application of soothing
ointments or from the employment of cauterizing agents. The growth
is always more extensive than the cutaneous involvement would indi-
cate and the only rational treatment is the amputation of the breast.
The X-rays should not be employed in this affection, except possibly
as a post-operative procedure.
Fig. 175. Model from Pospelow's Clinic in Moscow (^Fiweishy).
225
Carcinoma Linguae
Plate 109, Fig. 176
This lesion is, in over ninety per cent, of all cases, an epithelioma
similar entirely to epitheliomata of the lips, floor of the mouth, etc.
The high degree of malignancy which attends it is very seldom due to
internal metastases and ordinary cancerous cachexia but to the power
of rapid local extension and the high degree of glandular implication.
The location may vary in respect to any form of irritation which dis-
tinctly serves as a nidus for the neoplasm, but irrespective of this
fact it usually begins at the sides or tip of the organ.
Etiology
The disease occurs in the middle-aged, and its frequency is by no
means rare. The part played by so-called precancerous states, of
which there are a great number, is great, but cancer in this locality
may develop in a perfectly intact mucous membrane, and statistics
show that at least some of these preexisting lesions are notably ab-
sent. To enumerate the latter, there is the irritation from sharp
teeth, leukoplakia, syphilitic lesions and scars, glossitis and Rigg's
disease. Smoking is often accused as a source of constant irritation,
and is undoubtedly an important etiological factor.
Diagnosia
Since cancerous, tuberculous and syphilitic ulcers may occur on
the tongue, the main point is to exclude cancer, A negative Wasser-
mann generally excludes syphilis. Tuberculous ulcers are very rare,
the primary type especially ; the secondary form could readily be ex-
cluded. A suspicious induration or abrasion of the tongue may often
be recognized as cancer by excising a smaU fragment for microscop-
ical examination.
226
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Prognosis
This varies according to the duration and extent of the growth at
the time of operation.
Treatment
The only real benefit wrought is by early and radical operation.
Fig. 176. Model in St. Louis Hospital in Paris, No. 1557 (Baretta).
Hallopeau's case.
227
Carcinoma Penis
Plate 109, Fig. 177
The first manifestation is most commonly on the glans, the prepuce
being less frequently attacked. The initial and precancerous stages
show considerable variation, for this is described by patients as a
wart, pimple, raw surface, ulcer, scab, or smooth induration. The
lesion is almost invariably an epithelioma, and however it begins,
tends to invade the deeper tissues and proper lymph nodes. After
it has fairly begun the progress of the disease, which may be rapid,
follows one of two types: first a sort of rodent ulcer in which the
lesion consists of a rapidly extending ulcer with a hard border, and
second, a productive or papillomatous tj-pe which results in a so-
called cauliflower cancer. The two types shade into each other.
Although these growths may show much malignancy they are some-
times of very slow growth lasting for a number of years ; nor do the
glands always become involved. The proportion of cases which would
be comparable to superficial epithelioma and rodent ulcer of the face
is probably much larger than is commonly believed.
Diagnosis
Cancer of the penis has to be differentiated carefully from chan-
cre, syphilitic gumma and tuberculous ulcer, but the classic tests
should be sufficient for this purpose.
Prognosis
This is always grave.
Treatment
A few cases may be benefited by cauterization, curettage, or
excision, but in the great majority it is not only necessary to amputate
the penis but to remove all of the inguinal glands as well. Recurrence
is connnon, as elsewhere. Radium and the X-rays have their
advocates.
Fig. 177. Model in Neisser's Clinic in Breslau {Kroener).
228
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